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TREATISE 



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DISEASES OF THE BONES. 



BY 



EDWARD STANLEY, F.R.S. 

PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, 

AND 

SURGEON TO ST. BARTHOLOMEW'S HOSPITAL. 




PHILADELPHIA : 
LEA AND BLANCHARD. 

1849. 




" Quid dicam de ossibus ? quee subjecta corpori, mirabiles commissuras habent, et ad 
stabilitatem aptas, et ad artus finiendos accommodatas, et ad motum 5 et ad omnem cor- 
poris actionem." — Cicero, De Naturd Deorum, Lib. sec. 



O. S. COOKE & CO., PRINTERS, 
WEST BROOKFtELD; JiASS. 



DEDICATED 



TO 



^jMans [BMM¥ a mmM 



TREASURER 



dDf tji? Enpl luspitnl nf It. 35Ert|rnlnniBm, 



WHOSE ADMINISTRATION 



OF THAT NOBLE INSTITUTION 



IN THE SERVICE OF CHARITY AND OF SCIENCE, 



IS WORTHY OF ALL PRAISE. 



PREFACE. 



The admirable Lectures on the Diseases of Bone, with which Mr. 
Abernethy commenced his Anatomical and Physiological course, first 
incited me to the study of this subject. Observation, continued with 
some diligence through many years, and, in a large field of experience, 
has enabled me to accumulate the materials upon which the present 
volume is founded. The size of the volume bears no proportion to the 
number of the facts out of which it is constructed. For in this, as in 
other scientific investigations, the first object has been to obtain the 
facts, and the second to interpret them rightly for the conclusions they 
warrant. This I have endeavored to do, but with the result, I am 
aware, of leaving some of the morbid phenomena of bone uninterrupted, 
even unnoticed, for the reason that they were to me unintelligible. 
And I am induced to submit the work in its incomplete state, rather 
than detail in it characters of disease from which, in consequence of 
not understanding them, I should not be able to deduce either patho- 
logical conclusions or indications of treatment. 

I venture to think that others have experienced the difficulty which I 
.have felt, in the attempt to arrange and explain the subjects to be com- 
prehended in a Treatise on the Diseases of the Bones : otherwise, in an 
age remarkable for the fulness of its scientific literature, it might be 
expected that such treatises would have been produced. But the only 
works possessing this character, of which I have knowledge, are the 
Treatises of Petit, published in 1705, and of Boyer, in 1803. 

The liberal feeling, which happily prevails in our profession, is mani- 
1* 



VI PREFACE. 

fested through the following pages in the use that has been allowed me 
of the facts which others have observed. My acknowledgments on this 
head are sincerely offered to my colleagues at St. Bartholomew's Hos- 
pital. Especially to Mr. Lawrence these acknowledgments are due. 
Associated with him for many years, I have largely participated in the 
benefit he has conferred upon all around him, by the example of his 
untiring zeal and fidelity of observation, and by the liberality with which 
he never fails to communicate knowledge to all who are in search of it. 
I am also desirous of expressing to my able colleagues, Mr. Paget and 
Dr. Baly, my thanks for assistance in the preparation of this work. 

It is necessary to observe, that notwithstanding the references, which 
will be found in the following pages, to another volume, containing " Il- 
lustrations of the Effects of Disease and Injury of the Bones," the two 
works are, in all other respects, wholly distinct. The volume of Illus- 
trations contains, with the descriptions of the plates, full explanations of 
the subjects to which they relate, so that, in respect to these subjects, 
it is a complete and an independent work. 



INTRODUCTION, 



GENERAL CONSIDERATIONS ON THE DISEASES OF BONE. 

It is probable that Jean Louis Petit, in his " Treatise on the Diseases 
of the Bones," first observed the analogy hi their morbid changes to 
those of the soft parts of the body. Mr. Hunter, adopting the same 
view of the subject, represents " the bones in the causes of many of 
their diseases, in the termination of them and in their restoration, as 
similar to the soft parts.*" Mr. Abernethy, following out the same 
doctrine, referred to the phenomena which bone presents in disease as 
the proof of its vital organization.! Experience has proved the correct- 
ness of these views, and, accordingly, they are made the foundation of 
the following Treatise. 

Although it is true, that the diseases of bone are analogous to those 
of soft parts, yet they have their peculiar characters ; for in bone, as 
in other tissues, the rule holds that diseases are modified by the struc- 
ture and vital properties of the part they attack. 

Diseases of bone are generally characterized by slowness of progress. 
And it is equally so, whether the process tends to the advance or the 
recession of disease. Thus the exfoliation of the smallest piece of 
dead bone often requires many months for its completion ; and a much 
longer time is required for the osseous union or anchylosis of the sur- 
faces of bone, which, in the progress of disease in the spine, or in a 

* Lectures. t Lectures . 



yill INTRODUCTION. 

large joint, are brought into contact by destruction of the intervening 
tissues. Again, when the internal organization of a bone is deranged 
as in the softening of it from scrofula, even with the help of every 
strengthening influence upon the constitution, the reparation of the dis- 
eased bone is so tedious a process, that too frequently, from impatience 
in the treatment, sufficient time is not allowed for the bone to become 
again firm, and thereby fit for its functions. 

Eone is one of the less vascular tissues of the body ; yet it readily in- 
flames, and as readily throws forth granulations ; and in the reparation 
of its fractures, the osseous tissue itself takes a much larger share 
in the work of reparation than either the periosteum or medullary mem- 
brane. A more interesting view is not exhibited to the unaided sight 
of the pathologist than that of the changes which ensue upon an expos- 
ed liv-ing and healthy bone. First, its surface becomes of a faint red 
or pinkish tint, from the afflux of blood to its vessels ; then, bright red 
dots and streaks appear in the bone, which are the immediate precur- 
sors of the granulations from its tissues. These granulations appear as 
minute conical or round, soft papillae rising from the bone. When 
slightly touched, they freely bleed, and evince sensibility. Next, the 
granulations from the bone coalesce with those from the surrounding 
parts, and in this way the bone again becomes possessed of a covering 
of soft tissues. 

Bone possesses in its healthy state but little sensibility. But under 
circumstances of disease, its sensibility often becomes wonderfully ex- 
alted. Thus I have witnessed the manifestation of pain as acute from 
the penetration of an inflamed bone by a saw or trephine as from the 
incisions of inflamed soft parts. We observe, moreover, the granula- 
tions from diseased bone participating in' the morbid sensibility of its 
tissue. 

Such being the vital properties of bone, it is very liable to disease ; 
and its diseases are many, when compared with the diseases of muscle, 
tendon, or nerve, or indeed of any other organ or tissue. 

In respect to its original formation, development, and growth, bone 
is amenable to the same disturbing influences as the soft organs and 
tissues. Accordingly, there occur in bone congenital defects in out- 



INTRODUCTION". IX 

ward form, as well as in internal organization ; thus, in a child bom 
with vascular hypertrophy, of the character of naevus, extending through 
the soft parts on one side of the cranium and face, the bones were cor- 
respondency affected ; they were found to be very thick and spongy, 
and excessively vascular — they presented the characters of naevus in 
the osseous tissue.* 

"Whatever may be the source of the symmetry of diseases in soft 
parts, its influence extends to the osseous system. Exactly similar 
morbid conditions are constantly observed in the corresponding bones 
of the opposite sides of the body ; also in the halves of single bones. 
Thus the two thigh bones are often enlarged, indurated an d roughened 
on then surfaces, in so precisely the same manner and degree that not 
a morbid character can be pointed out in one of them which has not its 
fellow in the other ; and in the lateral halves of the frontal bone, iden- 
tical characters of disease are often observed. In animals, the eviden- 
ces of symmetrical morbid action are even more remarkable than in 
man. In the museum of the College of Surgeons there is the pelvis 
of a lion, which belonged to Mr. Hunter, exhibiting on its opposite sides 
the effects of hiflammation in the periosteum so perfectly alike, that not 
a rouglmess, eminence, or hollow can be detected on one side which is 
not exactly repeated on the other. Even the morbid growths from 
bone have appeared symmetrically ; thus there are instances of exosto- 
ses growing of the same size and form, and in the same situation, from 
the corresponding bones on the opposite sides of the body. 

It can scarcely be stated that the bones participate in all the dis- 
orders of the system, which directly give rise to depravation of the 
fluids circulating through the soft tissues, and, in consequence, to 
changes in then* component elements. "Whatever peculiar immunities 
from disease the bones evince, are, it may be presumed, owing to the 
character of their organization, in respect to the earthy constituents 
so largely entering into then composition. There are, however, in- 
stances in which the bones, participating in the general disorders of the 
system, do undergo changes in their elements, and throw forth morbid 
products of the same character as those occurring at the time in the 
softer tissues of the body. Thus in gout, the earthy phosphates in the 

* Museum of St. Bartholomew's Hospital, First series, No. 54. 



X INTRODUCTION. 

bones have diminished, peculiar products have been thrown forth from 
them, but they were such as are characteristic of the gouty constitution*. 

It is a peculiar feature in the morbid history of bone, that the irrita- 
tion of disease, however excited in it, is so commonly followed by the 
action of forming osseous substance among the surrounding soft parts, 
some of these being more prone to this action than others ; hence, the 
ossification ensuing in the various structures adjacent to diseased, or in- 
jured, bones. Here, moreover, it may be well to regard in one view 
the whole series of ossifications and osseous productions arising either 
as distinct diseases, or as the consequence of disease in their neighbour- 
hood. Morbid ossifications and osseous productions may be arranged 
under the following heads : — 

1. Unorganized masses of calcareous salts, found in various tumors, 
especially in the fibrous tumours of the uterus, also constituting 
the apparent ossifications in the coats of arteries. 

2. Ossifications of original tissues, as of fibrous membrane, tendon, 
muscle, &c. These are, probably, but the ossifications of one tis- 
sue, the cellular, a component of all these structures. 

Fibrous membranes are remarkably prone to ossification ; one ex- 
ample of which, among many, is the long-enduring ulcer upon 
the leg, followed by ossification of the periosteum beneath the 
ulcer and around it, accompanied by ossification of the inter-osse- 
ous ligament between the tibia and fibula, often converting it into 
a thick plate of bone. The character of its organization is not 
the sole cause of the tendency of fibrous membrane to ossify. Its 
vital properties, and its locality in connexion with the purposes it 
serves, are also to be taken into account in explanation of the ex- 
ception that some fibrous membranes, as the muscular aponeuroses, 
or fasciae, very rarely ossify. So in respect to the pericranium, 
which in its structure is not distinguishable from the periosteum of 

* Chemical Composition of Concretions from Gouty Bones, Marchand, Journal f. 
Pract. Chemie. Oct. 1842. 

Urate of Soda . . - . . 34-20 



Urate of lime 
Carbonate of lime . 
Chloride of sodium 
Water . 

Animal substance ♦ 
Loss 



212 

7.68 
14-12 

680 
32-53 

2-37 

100-0 



INTRODUCTION. XI 

other bones ; yet the ossification of its texture does not occur. 
Osseous tumors, it is is true, are found upon the cranium, but they 
have originated in the bone, not in the pericranium. 

All these ossifications of original tissues, when completed, exhibit in 
the miscroscope, in different instances, more or less of the charac- 
ters of true bone. 

3. Growths of perfect bone. Most of these are productions from 
orioinally formed bone, but they are not invariably so : some of 
these growths are found in cellular tissue, and have no connexion 
with the adjacent bones. The osseous tumours growing from' 
bones are of three kinds : one consists in a circumscribed hyper- 
trophy of the bone from which the tumor grows ; this is not pre- 
ceded by cartilage, it is usually cancellous, and its composition is, 
the same as true bone. Another osseous tumor growing from- 
bone is that which is of most frequent occurrence, the genuine ex- 
ostosis, which is preceded by the formation of cartilage, and 'com-- 
posed of true bone, and is usually a local malady of an innocent 
nature. The third form of osseous tumor growing from bone 
includes varieties in respect to its composition and character, and 
some of these exhibit features of malignancy. One of the most 
conspicuous of such growths is the Osteoid Tumor of Muller. 

Many, and remarkably varied, are the characters of disease in bone ; 
yet it is not to be doubted that each of its morbid changes is the defi- 
nite character of but one disease. For example, the thickenings, in- 
durations, and ulcerations of bone exhibit various features in corres- 
pondence with the variety of the causes producing them. So with re- 
spect to the syphilitic worm-eaten ulcer of bone, its characters are so 
distinct that no other disease can be mistaken for it ; but there are va- 
rieties in the syphilitic ulcer of bone corresponding, Mr. Paget has ob- 
served, with the varieties of the syphilitic eruption and ulcer in soft 
parts. 

Bone holds a high place among the animal structures, in respect of 
the provision made for its reproduction when lost by injury or disease. 
If a portion of tendon, or muscle, perishes and sloughs away, no repro- 
duction of it ensues. The portion of bone, on the other hand, which 
perishes and exfoliates, is, under certain circumstances, replaced. In- 
deed it may be affirmed, that no where else in the animal body does so 
perfect an instance of reproduction occur as in certain eases of necro- 



XU INTRODUCTION. 

sis, where the shaft of a bone with its compact walls, cancellous tex- 
ture, medullary tube, membrane, and medulla, are all reproduced with 
every essential feature of their original organization. 

Experiments in animals have not accomplished so much for the eluci- 
dation of the reparative processes of bone in man as might probably 
have been expected. The circumstances attendant on the fractured or 
necrosed bone, in man, are essentially different from those of the ex- 
periment of breaking, or causing the death of a bone in animals. 
Thus, around the fractured bone of an animal, the deposit of cartila- 
ginous and osseous substance, which has been designated provisional 
callus, is of uniform occurrence. But, in the human subject, no such 
cartilaginous and osseous deposit uniformly takes place around the 
fractured bone ; here, therefore, it is not an essential part of the re- 
parative process. Also, with respect to the production of necrosis by 
experiment in animals, the condition of the surrounding soft parts is so 
materially different from the condition of these parts preceding and ac- 
companying the death of the shaft of a bone in man, that, in conse- 
quence, the features of the reparative process in the two cases are 
essentially different. It has, therefore, been incorrectly assumed, that 
because such is the reparative process of fracture, or necrosis, in ani- 
mals, it must be so likewise in man. 



ARRANGEMENT OF THE SUBJECTS 



PART I. 

Chap. I. — Hypertrophy of Bone. 
Atrophy of Bone. 
II. — Neuralgia of Bone. 
III. — Inflammation of Bone. 
Enlargement of Bone, \ 

a. By expansion of its Tissue. 

b. With induration of its tissue. 

e. By Osseous Deposits on its Surface. 
IV.— Suppuration in Bone. 
V. — Caries. 

VI. — Ulceration of Bone. 
VII. — Death of Bone : Necrosis. 

PART II. 

Tumors of Bone. 

a. Tumors of Bone which pulsate. 

b. Osseous Growths arising in considerable 

numbers from the Skeleton, and in the 
Soft Tissues. 

PART III. 

Chap. I. — Rickets. 

II. — Conditions of Bone designated Mollities and. 

Eragilitas Ossium. 
IH. — Scrofula in bone. 
IV. — Hard Carcinoma, Melanosis in Bone. 

PART IV. 

Chap. I. — Morbid Growths from the Jaws. 

II. — Diseases of the Bones of the Spine. 
IH. — Diseases of Periosteum. 

2 



CONTENTS. 



INTRODUCTION. 



Analogy in the diseases of bone to those of soft parts .... 

Diseases of bone of slow progress - s . . . . 

Vascular character of bone, its liability to inflammation, phenomena of its granu- 
lating process ......... 

Sensibility of bone, its exaltation by disease ..... 

Many diseases of bone by comparison with other organs and tissues 

Congenital defects of the outward form and internal organization, nsevus in bone 

Symmetrical morbid actions in bone ...... 

Peculiar immunities from disease in bone, owing to its earthy constituents 

Morbid ossifications and osseous productions, the consequence of the irritation of 
disease in bone ......... 

Arrangement of morbid ossifications and osseous productions 

Great variety in the characters of disease in bone ; every disease in bone its defi- 
nite character ......... 

Bone compared with other structures, in respect to the provisions for its reproduc- 
tion ........... 

Experiments in animals, failure to illustrate the reparative processes of bone in man 



PAGE 
vii 
vii 



vm 
viii 
viii 
viii 
ix 
ix 

x 
x 



XI 

xii 



PART I 



CHAPTER I. 



HYPERTROPHY AND ATROPHY OF BONE. 



Hypertrophy of bone 

Examples of hypertrophy . 

Influence of remedies on hypertrophy 

Hypertrophy of the bones of the face 

Hypertrophy of the bones of the lower extremity, consequences of it 

Circumscribed hypertrophy simulating exostosis 

Atrophy of bone .... 

Causes of atrophy .... 

Atrophy with defective growth 

Defective growth of bone from disease 

Defective growth in bones of the lower extremity, its consequences 



25 
25 
27 
27 
23 
28 
29 
29 
30 
30 
30 



CONTENTS. XV 



CHAPTER II. 

NEURALGIA OF BONE. 

, PAGE 

History of the affection ........ 32 

Neuralgia simulating inflammation, abscess in hone . . . .32 

Diagnosis betAveen neuralgia and inflammation of bone . . . .32 

Examples of neuralgia of bone ....... 33 



CHAPTER III. 

INFLAMMATION OF BONE. 

Vascularity, sensibility of inflamed bone ...... 37 

Morbid products from inflamed bone ...... 37 

Reciprocal actions of disease in bone, periosteum, and medullary membrane . 38 
Enlargement of bone by expansion of its tissue ..... 38 

Characters of expanded bone ....... 38 

Enlargement of bone, with induration of its tissue . . . .39 

Characters of indurated bone . . ..... 39 

Causes of induration of bone ....... 40 

Changes in the articular ends of bone from rheumatism . . . .41 

Influence of medicines upon induration of bone ... 41 

Enlargement of bone by osseous deposits on its surface . . . .41 

Rheumatic inflammation of periosteum the frequent cause of these deposits . 42 
Difficulty in the diagnosis of the various enlargements of bone . . .42 

Enlargement of the cranial bones not the effect of ossification of the pericranium 43 
Nervous affections coincident with enlargements of the bones of the skull . 43 

Epilepsy, insanity, tic doloureaux — their connexion with enlargements of the bones 
of the skull ......... 43 

General considerations on the treatment of inflammation of bone . . 44 

Principles of treating inflammation of bone . . . . .44 

Remedies for inflammation of bone . . . . . . .44 

Local remedies ... ...... 44 

Internal remedies, iodide of potassium, its efficacy . . 44 

Influence of iodide of potassium on the syphilitic affections of bone . . 45 

Influence of mercury upon the acute affections of bone . . . .45 

Counter-irritation, its influence upon the painful enlargements of bone . . 46 

Considerations regulating the use of counter-irritation . . . .46 



CHAPTER IV. 

SUPPURATION IN BONE. 

Abscess in bone, its distinction into circumscribed and diffused . . .48 

Character of the circumscribed abscess ...... 48 

Circumscribed abscess preceded by tubercle in bone . . . .48 



XVI CONTENTS. 

PAGE 

Circumscribed abscess, mode of its enlargement . . . . .50 

Diffuse suppuration in bone, its formidable character .... 50 

Causes of diffuse suppuration in bone, example of it after amputation . . 50 
Diffuse suppuration in bone, its combination with suppuration in veins, purulent 

deposits in distant parts . . . . . .51 

Obscurity in the symptoms of diffuse suppuration in bone, how arising, example of 

it in the humerus ......... 51 

Diffuse suppuration in bone accompanied by necrosis, example of it in the tibia . 52 

Cases illustrating the history of inflammation in the medullary membrane . 53 

Diagnosis of abscess in bone ....... 55 

Treatment of suppuration in bone ....... 57 

Consideration of the measure of perforating the bone for the discharge of matter 

from it ......... 57 

Mode of perforating a bone ........ 58 

Consideration of the perforation of the outer table of the skull, for the discharge of 

matter from its diploe ........ 59 

Combination of suppuration in the diploe, with necrosis of the outer table of the 

skull 59 

CHAPTER Y. 

ON CARIES. 



Definitions of caries 
Varieties of caries . 
Phenomena of caries 
Diagnosis qf caries . 
Treatment of caries . 
Influence of depletory remedies on caries 
Natural processes of cure of caries, considerations respecting the operation of 
moving carious bone ....... 

Incisions of the soft parts covering carious bone — effect of local applications to 



61 
61 
61 
62 
63 
63 

63 
64 



Instances of caries unsuited for operation ...... 65 

CHAPTER VI. 

ULCERATION OF BONE. 

Ulceration of bone analagous to ulceration of soft parts . . . .67 

Varieties of ulcer in bone . . . . . . . .67 

Characters of ulcerated bone ....... 68 

Ulceration of bone, a primary disease in the vertebra?, in the articular surfaces of 

bone .......... 68 

History of ulceration of the head of the femur ..... 69 

Ulceration of the articular surfaces of bones in the progress of the inflammatory 

disease of joints, its characters and consequences . . . .69 

Reparation of ulcerated bone ....... 70 

Eeproduction of the cancellous substance of bone removed by ulceration — osseous 

anchylosis .......... 70 



CONTENTS. 



xvu 



Reproduction of the compact substance of bone removed by ulceration 
Treatment of ulceration of bone .... 
Local remedies applicable to ulcerated bone 
Influence of counter-irritation on ulcerated bone 
Phagedenic ulceration of bone .... 

History of the disease, examples of it 



PAGE 

70 
70 
70 
71 
71 
71 



CHAPTER Vn. 



NECROSIS. 



Definition of necrosis, modes of its occurrence ..... 

Characters of dead bone ........ 

Comparative frequency of necrosis in the cancellous and compact tissue of bone 

Liability of different bones to necrosis . ..... 

Peuliar tendency in the head of the tibia to disease .... 

Causes of necrosis ......... 

Removal of periosteum — consequent death of the outer lamellse of the bone 

Necrosis of the upper or lower jaw,, how usually arising .... 

Necrosis of the lower jaw from scurvy, from excessive salivation . 

Necrosis of the jaws in lucifer-match manufacturers .... 

Disease in the bones of cows, apparently from the influence of the fumes of arsenic 

Necrosis of tuber ischii, trochanter major, from pressure .... 

Necrosis of scrofulous bone ....... 

Necrosis consequent on syphilis ....... 

Necrosis from rheumatic inflammation of periosteum — examples of it in the tro- 
chanter major ......... 

Consideration of the fistulous passage in the soft parts as a character of necrosis 

Symptoms of necrosis ........ 

Characters of necrosis of the outer lamellse of a bone .... 

Characters of necrosis of the inner lamella? of a bone .... 

Characters of necrosis of the shaft of a bone in its whole thickness , 

Question of the death of the medullary tissue from necrosis of the walls of a bone 

Necrosis near the articular end of a bone — extension of inflammation to the adja- 
cent joint .......... 

Mildness of the inflammatory changes in the soft parts around a dead bone, under 
what circumstances observed ..... 

History of necrosis in the head of the tibia 

Mode of separation of dead from living bone 

Analogy of exfoliation to the separation of a slough from soft parts 

Phenomena of exfoliation, observed in man and in animals 

Analogy of exfoliation to the shedding of the antlers in deer 

Pirst investigation of exfoliation as a vital process, by Hunter 

Investigation of exfoliation by the microscope 

Chemical qualities of the pus from parts adjacent to exfoliating bone 

Mode of removal of dead bone . 

Disappearance of dead bone without sensible exfoliation, examples of it 

Agency of granulations in removing dead bone 

Removal of dead bone in particles, by a process designated insensible exfoliation 

2* 



74 

74 
74 
75 
75 
75 
75 
76 
76 
76 
79 
80 
80 
80 

80 
81 
82 
83 
82 
83 
84 

84 

84 
85 
86 
86 
87 
87 
88 
88 
89 
89 
90 
90 
90 



XVU1 CONTENTS, 

PAGE 

Size of an exfoliated piece of bone in relation to the space in the living bone . 91 
Pulsatile movement in the matter adjacent to exfoliating bone . . .91 

Extrusion of exfoliated bone, how effected ...... 91 

Question of the removal of exfoliated bone by the living parts . . .91 

Adhesion of the living parts to dead bone ...... 92 

Exfoliation an uncertain process ....... 93 

Separative processes consequent on necrosis ..... 93 

Question of reproduction of the outer lamella? of a bone . . .94 

Phenomena consequent on the death of the outer lamella? of bones in animals 

— experiments of Hunter . . . . . . 95 

Removal of the entire periosteum of the shaft of a bone in animals — the reparative 
process . . , . . . , . . . .95 

.Activity of the reproductive power possessed by medullary tissue . . 96 

Necrosis of the walls of a bone — reproduction by the periosteum . . 96 

Necrosis of the inner lamella? of a bone — the reproductive process , . 96 

Necrosis of the entire inner lamellae of a bone — separation in the form of a tube 96 
Necrosis of the entire thickness and circumference of the shaft of a bone — the re- 
productive process ........ 97 

Reproduction by periosteum considered .".... 97 

Question of reproduction by portions of the old bone separated with the periosteum 100 
Reproduction from the articular ends of the original bone . . . 101 

Question of reproduction by the surrounding soft parts .... 101 

Periosteum of the new bone, how formed ...... 102 

Holes in the walls of the new bone, how arising, consequences of them . .102 

Composition of the new bone ....... 103 

Detachment of the articular ends of the original bone before the new bone has ac- 
quired firmness, consequences ....... 103 

Uncertainty in the time required for reproduction of the shaft of a bone . 104 

Cases of necrosis most favourable for the reproductive process . . . 104 

Cases of necrosis not followed by any reproductive process . . .105 

Necrosis of flat bones — question of their reproduction . . . .105 

Necrosis of the ilium — its consequences ...... 105 

Question of reproduction of short cylindrical, irregularly-shaped bones . . 106 

Instances of necrosis followed by no change in the dead bone and by the closure 
of the fistulous passage leading to it . . . . . .106 

Productions of new bone adherent to dead bone — question of the mode in which 
this happens . . . . . . . . 107 

References to least frequent examples of necrosis . . . . 108 

Treatment of necrosis ........ 108 

Applications to the soft parts around dead bone . . . . .108 

-Applications to the dead bone ....... 109 

Superficial necrosis — removal of the dead bone by operation . . .110 

Deep-seated necrosis — removal of the dead bone by operation . . .110 

Mode of extracting dead bone . . . . . . .110 

Treatment of necrosis of the shaft of a bone . . '. . .Ill 

Question of the removal of the dead shaft of a bone . . . .113 

Necrosis within the head of the tibia — question of the removal of the dead bone 114 
Necrosis of the shaft of the tibia — removal of the dead bone . . .114 

Necrosis of the humerus — removal of the dead bone . . . .115 

Necrosis of the lower part of the femur — removal of the dead bone . • 116 

Treatment of necrosis of the bone of a finger or toe . . . . 116 

Illustrations of operative proceedings for the removal of dead bone -. . 117 



CONTENTS. 



XIX 



PART II. 



TUMORS OF BONE. 



Characters of the morbid growths from bone 

Arrangement of the tumors of bone .... 

Principal products found in the tumours of bone . 

Tumour of bone composed chiefly of cartilaginous substance 

Two forms of the cartilaginous tumor .... 

Characters of the cartilaginous tumor .... 

Diagnosis of the cartilaginous tumor .... 

Progress of the cartilaginous tumor to a large size, changes in it 
Influence of remedies upon the cartilaginous tumor 
Cartilaginous substance combined with other morbid products . 
Tumor of bone composed chiefly of osseous substance . 
Exostosis, composition ...... 

Mode of formation and growth — primordial cartilage 

Varieties of exostosis 

Distinction between exostosis and enchondroma 

Figure — size of exostoses . 

Many exostoses in the same individual 

Diagnosis of exostosis 

Exostosis from the bone of a finger or toe 

Consequences of exostoses . 

Exostosis from the bone of a toe — its characters, consequences 

Treatment of exostosis 

Eemoval of exostoses by operation 

Mode of removing exostosis from the last bone of a toe 

Exostosis from the femur close to the knee-joint, its removal by operation 

Bemoval of hard exostoses 

Spontaneous separation of exostoses 

Suppuration within an exostosis . 

Malignant osseous (osteoid) tumor 

Characters of the malignant osseous tumor 

Instances of the malignant osseous tumor 

Tumor of bone composed chiefly of encephaloid substance 

Characters and progress of the encephaloid tumor 

Diagnosis of the encephaloid tumor 

Question of amputating a limb, the seat of the encephaloid tumor of bone 

Tumor of bone, composed chiefly of fibrous tissue 

Characters of the fibrous tumor .... 

Diagnosis of the fibrous tumor .... 

Tumor of bone, composed chiefly of gelatinous substance 

Characters of the gelatinous tumor 

Tumor of bone, composed chiefly of fatty substance 

Characters of this tumor , 

Tumor of bone, composed of a soft substance, of the character of erectile tissue 



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CONTENTS. 



PAGE 

Characters of this tumor . . . , . . . .155 

Tumor of bone composed chiefly of blood . . . . . 156 

Characters and progress of this tumor . . . . . .156 

Question of the sanguineous tumor being a variety of encephaloid disease . 157 
Tumor of bone consequent on the production of entozoa within it . . 158 

Characters and progress of the hydatid tumor of bone . . . .158 

Diagnosis of this tumor . . . . . . . .159 

Treatment of hydatids in bone ....... 161 

Tumor of bone consequent on the formation of membranous cysts within it . 162 
Characters of this tumor . . . . . . . 1 62 

General considerations relative to the diagnosis and prognosis of the tumors of 

bone . . . . . . . • . . .162 

Tumors composed of soft substance, yet incompressible . . . .163 

Tumors having the hardness of bone . . . . . .163 

Tumors so soft as to be readily compressible . . . . . 163 

Degree of fixedness of the tumor, as evidence of its connexion with the bone . J 64 

Enlargement and tortuosity of the veins ramifying over the tumor . . 164 

Condition of the absorbent glands adjacent to the tumor . . . .164 

Anomalous character produced in the tumor by the flow of blood into it from an 

ulcerated artery . . . . . . . . .164 

Displacement of blood-vessels by the tumor . . . . .165 

Tumors of bone which pulsate . . . . . . .166 

Varieties of pulsating tumor . . . . . . .166 

Sources of pulsation . . . . . . . .167 

Treatment of the pulsating tumor . . . . . . .170 

Examples of the result of treatment • . . . . .170 

Difficulties in the diagnosis of the pulsating tumor . . . .172 

Pulsating tumors arising from many bones . . . . .173 

Osseous growths in considerable numbers from the skeleton and in the soft tissues 174 



PART III. 

CHAPTER I. 



RICKETS. 

Characters of the disease . . . . . . . .179 

Usual period of its appearance . . . . . . .179 

Condition of rickety bones . . . . . . .179 

Figure of rickety bones . . . . . . . .180 

Condition of the skull . . . . . . , .181 

Condition of the spine, its distortions . • . . • .182 

Distortion of the chest . . . . . . . .183 

Changes in the form of the pelvis . . . . . . .183 

Condition of the thigh bones . . . .' . . .184 

Arrest of growth in rickety bones . . . . . .184 

Distortions of the joints . . . . . . .184 

Question of the progressive changes in the bones from the lower to the higher 

parts of the skeleton . . . . . . . .185 



" CONTENTS. XXI 

PAGE 

Eeparation of rickety bones . . • . . . .186 

Causes of rickets . . . . • • • • 187 

Co-existence of rickets with tubercle in the lung . . . .187 

Treatment of rickets . . . • • • • .188 

CHAPTER II. 

MOLLITIES AND FRAGILITAS OSSIUM. 

Histories of cases in which the bones were softened . . . .190 

Histories of cases in which the bones were thinned in their walls, giving rise to 

spontaneous fractures . . . . . . . .193 

Examples of tins condition . . . . . . .195 

CHAPTER ni. 

SCROFULA IN BONE. 

Forms of scrofulous disease in joints . . . . . .199 

Changes in bone from scrofula ....... 200 

Question of the curability of scrofulous bone ..... 200 

Question of the reproduction of bone destroyed by scrofula . . . 201 

Question of the co-existence of tubercle in bone with its deposit in the lungs . 201 

Changes from scrofula occurring in many bones ..... 202 

Treatment of scrofula in bone ....... 202 

Length of time required for the cure of scrofula in bone . . . 203 

CHAPTER IY. 

HARD CARCINOMA AND MELANOSIS IN BONE. 

Characters and progress of carcinoma in bone ..... 205 
Melanosis in bone ......... 208 



PART IV. 

CHAPTER I. 

MORBID GROWTHS FROM THE JAWS. 

Disease of the gum designated epulis . . . . . .211 

Characters, progress of this disease . . . . . .211 

Disease originating in the gum, &c. designated epithelial cancer . .212 

Characters and progress of this disease ...... 213 

Treatment of epulis and of epithelial cancer ..... 213 

Question of the removal of epithelial cancer co-existing, with enlargement of the 
absorbent glands . . . . . . . .214 



XXII 



CONTENTS. 



PAGE 

Morbid growths from tlie lower jaw . . . . . .216 

Varieties of morbid growth from the lower jaw . . . , .216 

Characters, progress of morbid growths from the lower jaw . . .218 

Operations upon the lower jaw ....... 220 

Various directions of the incisions in the soft parts .... 220 

Steps of the operation of removing a portion of the lower jaw . . .221 

Removal of the alveolar border of the jaw . . . . .221 

Consequences of removing the front of the lower jaw .... 222 

Means of remedying these ....... 222 

Removal of the ramus of the jaw . .... 222 

Retraction of the tongue following the removal of the front of the jaw . 223 

Reproductive power ensuing upon the removal of part of the lower jaw . 224 

Removal of both lateral portions of the jaw, leaving the symphisis . . 224 

Morbid growths from the upper jaw .... . . 224 

Particulars in the anatomy of the antrum ..... 225 

Lines of connexion of the superior maxillary with the adjacent bones . . 226 

Explanation of the frequent origin of morbid growths in the antrum . . 226 

Morbid growths in the antrum, periods of their occurrence . . . 227 

Varieties of morbid growth from the superior maxillary bone . . . 227 

Malignant ulceration of the walls of the antrum unaccompanied by morbid de- 
posit . . , ... . . . . . 228 

Epulis extending into the antrum ...... 228 

Diagnosis of enlargements of the antrum ..... 228 

Progress of tumors in the antrum ...... 229 

Mode of investigating tumors of the antrum ..... 230 

Question of operation, on what it rests ...... 231 

Operations upon the superior maxillary bone , 231 

Mode of extracting a morbid growth from the antrum . . . . 232 

Removal of the superior maxillary bone ..... 232 

Considerations on the question of removing part, or the whole of the superior 
maxillary bone ........ 233 

Disease limited to the nasal portion of the maxillary bone, mode of its removal 234 
Mode of removing the entire maxillary bone ..... 234 

Consequences of the removal of the maxillary bone, means of remedying these 236 
Instance of hypertrophy of the superior maxillary bone, operation of its removal 237 
Membranous cysts connected with the alveolar process of the upper jaw . 239 

Characters , progress of the disease ...... 239 

Treatment of it . . . . . . . . , 240 

Treatment of accumulations of fluid within the antrum . . .241 

Treatment of suppuration in the antrum ...... 241 



CHAPTER II. 



DISEASES OF THE BONES OF THE SPINE. 



Varieties in the diseases of the spine .... 

Structural changes from inflammation in the spine 

Most frequent causes of inflammation in the coverings of the spine 

Suppuration beneath the coverings of the spine . 

Inflammation in the bone of the spine occurring in the course of fever 



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CONTENTS. 



XXlll 



Suppuration into the cancellous texture of the vertebrae 

Ulceration of the bones of the spine, its frequency 

Examples of ulceration of the vertebras from injury . 

Symptoms, progress, and consequences of ulceration of the vertebrae . 

To what extent is ulceration of the vertebrae reparable . 

Disease commencing in the inter- vertebral fibro-cartilages 

Scrofulous disease in the bones of the spine ... 

Characters and progress of this disease ..... 

Distortions of the spine ensuing from disease of the bones and fibro-cartilages 
Consequence of the destruction of the bodies of the vertebras . 
Consequence of the destruction of the arches of the vertebrae . 
Irregularities in the spinous processes from original formations . 
Destruction of the bodies of the cervical vertebrae, the consequent distortion 
Destruction of the bodies of the dorsal vertebrae, the consequent distortion 
Destruction of the bodies of the lumbar vertebrae, the consequent distortion 
Destruction of the inter-vertebral fibro-cartilages, the consequent distortion 
General remarks on the symptoms of disease in the spine 
Question of pain in the spine being the evidence of disease in it 
Symptoms of affection of the spinal cord and nerves, ensuing from disease in the 
.spine ....... 

Treatment of disease in the spine 

Rule of treatment applicable to all diseases of the spine 
Local depletion, question of its use 
Consideration of the use of mercury 
Treatment of inflammation of the investments of the spine presumed to be rheu 
matic ...... 

Treatment of paraplegic affections presumed to have been of inflammatory origin 
Question of the utility of counter -irritation in disease of the spine 
Slow progress of the reparative processes ensuing upon disease of the spine 
Caution in deciding upon the condition of a spine which has been the seat of 
disease ....... 

Psoas abscess ...... 

Seat of psoas abscess ..... 

Occasionally unaccompanied by disease of the spine 
Effect of the psoas abscess upon the spinal cord . 
Varieties in the progress of psoas abscess 
Psoas abscess in the thigh simulating adipose tumor 
History of iliac abscess, distinctions between it and psoas 
Treatment of psoas abscess .... 

Diseases in the first and second cervical vertebrae 
Malignant diseases of the spine .... 



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CHAPTER III. 



DISEASES OF PERIOSTEUM. 

Causes, effects of inflammation of periosteum . 

Inflammation of periosteum from syphilis, its effects . 

Inflammation of periosteum from scrofula, various changes to which it gives rise 



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xxiv 



CONTENTS. 



Inflammation of periosteum near a joint, consequences of it 
Inflammation of the periosteum of the pelvis, mistaken for disease in the hip 
joint ......... 

Examples of this disease ...... 

Inflammation of the periosteum of the trochanter major of the femur 

Treatment of inflammation of periosteum 

Incision of inflamed periosteum ..... 

Illustration of varieties of periostitis .... 

Malignant disease of periosteum ..... 

Characters, progress of the disease .... 

Grounds of the opinion of its malignancy- 
Examples of this disease ...... 

Diagnosis of it . 



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PART L 



CHAPTER I. 



HYPERTROPHY AND ATROPHY OF BONE. 

The changes which occur in bone from hypertrophy and atrophy are 
remarkable in respect to the close connexion they establish between 
the vital actions in bone and those in the softer tissues. But there is a 
higher interest in the history of hypertrophy and atrophy of bone, from 
the practical questions involved in the phenomena to which they give 
rise. 

HYPERTROPHY OP BONE. 

This condition of bone consists in an increase of its size from 
the augmentation of its healthy tissue. Long bones are often thus in- 
creased in thickness, but rarely in length. I have, however, seen in- 
stances of long bones hypertrophied in their length. In the museum 
of the university of Bonn I saw the skeleton of a young female, in 
which the tibia and fibula are hypertrophied in thickness, and in its 
length to the extent of three inches. When a bone is hypertrophied 
only in its length, it may seem that the apparently greater length of it 
is the consequence of defective growth in the corresponding bone of 
the opposite limb. But when a bone is increased in thickness, and 
also in its length, its hypertrophied condition is then distinctly marked. 

Instances occur of hypertrophy in the tibia, whilst the fibula under- 
goes no change. Under such circumstances, either the hypertrophied 
tibia will become curved, or the ligaments uniting it to the fibula will 
yield with the increase of its length ; and I have seen instances of both 
these occurrences. 

The following are examples of hypertrophy in long bones : — 

Hypertrophy of the Tibia in its Thickness and Length. A girl, 
3 



26 ON HYPERTROPHY 

aged twelve years, was admitted into St. Bartholomew's Hospital with 
scrofulous ulcers along the front of the leg. Beneath the ulcers the 
shaft of the tibia was so considerably increased in thickness, that its 
width across its front surface was double that of the opposite tibia, and 
the hypertrophied tibia was also increased in length to the extent of an 
inch. The disease had been six years in progress, and it had been ac- 
companied by repeated ulcerations along the front of the leg, which, it 
appeared to me, were the consequence of inflammation of the perios- 
teum of the hypertrophied bone. 

Hypertrophy of the Tibia in its Thickness and Length. A boy, 
aged fourteen years, with a strongly marked scrofulous constitution, was 
admitted into St. Bartholomew's Hospital. Four years previously an 
abscess formed in the thigh, and on the cessation of the discharge from 
it, the tibia in the opposite leg began to enlarge. The tibia was not 
only much increased in thickness, but also in length, to the extent of 
an inch and a half. The periosteum of the hypertrophied bone was 
much thickened. To relieve himself from the inconvenience of the 
unequal length of his legs, he had acquired the habit of walking with 
his knee slightly flexed and his foot twisted outwards. 

Hypertrophy of the Tibim and Fibular in their Thickness and Length. 
A boy, aged fifteen years, was admitted into St. Bartholomew's Hos- 
pital with ulcers along the fronts of both legs. Both tibiae were greatly 
increased in thickness, and arched forwards. The fibulas were also 
increased in thickness, and arched, but in a less degree than the tibiae. 
Both legs appearing to be of unnatural length in relation to the thighs, 
to determine whether they were so, I measured the tibia in several in- 
dividuals about eighteen years of age, and found its average length to 
be little more than eleven inches, but in this boy, who was fifteen years 
of age, each tibia was found to be thirteen inches and a quarter long ; 
thus showing the hypertrophy in its length to the extent of two inches. 
The boy stated that the enlargement of the bones of his legs com- 
menced at the age of three years, without apparent cause, and that 
during its progress there had been many attacks of ulceration in the 
integuments, followed by exfoliations from the hypertrophied bones. 

I have seen instances of hypertrophy in the long bones of the upper 
limbs ; and the subjects of this change in the bones were young, with 
decided marks of a scrofulous constitution. 

The enlargement of bone by hypertrophy is unaccompanied by pain : 
it advances very slowly, its progress often extending through several 



AND ATROPHY OF BONE. 27 

years. Thickening of the periosteum often accompanies the enlarge- 
ment of the bones, and ulcerations often occur in the integuments cov- 
ering them, followed by small exfoliations from the hypertrophied bones. 

It is very doubtful whether remedies local or constitutional have 
any other effect on these hypertrophies of the long bones than that 
of removing the irritation of the periosteum covering them. To this 
extent the local application of iodine, and the internal use of iodide of 
potassium with sarsaparilla, are certainly beneficial. But I do not 
think that these, or any other remedies, will effect a diminution of the 
bones : once enlarged, they will, I believe, permanently remain so. 

Hypertrophy occurs in bones composed wholly of cancellous texture, 
and frequently in the bones of the face, where it constitutes a disease 
which, on account of the deformity and other evils attendant on its in- 
crease, may require removal by operation. 

Hypertrophy of the bones of the face usually begins in early life, 
and most frequently in the superior maxillary bone. In some cases it 
is a direct consequence of injury to the part by violence, but in others 
it camiot be traced to any such cause. The enlargement of the bones 
usually advances so slowly, that its progress, jvhen the bones are exam- 
ined at short intervals, is often scarcely perceptible. It is unaccompa- 
nied by pain, or even tenderness, in the soft parts investing the enlarg- 
ed bones, and it does not affect the general health. 

Hypertrophy commencing in the superior maxillary bone often ex- 
tends through the whole of it, and into the adjacent bones, causing the 
enlargement of them, and frequently the obliteration of the cavities of 
which they constitute the boundaries. Thus the antrum becomes ob- 
literated, the nasal passages, also the orbit contracted, with dis- 
placement of the eye from its cavity ; and in some cases the osseous 
deposit goes on to the extent of forming irregular bosses of hard osse- 
ous substance, projecting from the enlarged bones either to the outside 
of the face or into the nasal and orbitar cavities. 

With respect to the treatment of the hypertrophied bones of the 
face, I can only state, that medicines have no influence upon the dis- 
ease. The only practical consideration that can arise respecting it, is 
whether the enlarged bones should be removed by operation, when the 
disease is manifestly increasing, with its deformity and other attendant 
evils ; and when, on this ground, the propriety of an operation is con- 
sidered, there will probably be difficulty in determining the exact boun- 
daries between the healthy and diseased bones, since the extent of the 
latter is not indicated by any morbid change in the soft parts covering 



28 ON HYPERTROPHY 

them. I venture, however, to state, that in such cases it need not be 
a rule from which there should be no deviation, that, as the only justifi- 
able ground of operation, the whole of the diseased parts must be tak- 
en away. I know that in cases where only part of the hypertrophied 
bones has been removed, the wound was healed soundly over the re- 
maining portion of them ; and it has not in such instances appeared 
that the operation was followed by any increase of the disease. 

One consequence of hypertrophy in any of the long bones of the 
lower extremity deserves further notice, namely, the inequality in the 
length of the limbs, giving rise to much inconvenience and awkward- 
ness in the gait, which I have known to be referred to disease in the 
hip joint. A man, aged thirty-five, had, since he was twelve years old, 
suffered from the formation of many small abscesses in different parts 
of the thigh, accompanied by trifling exfoliations from the femur, and 
during the whole of this time he had noticed a gradually increasing ex- 
cess in the thickness and length of the thigh by comparison with the op- 
posite limb ; at the same time his movements had become very awk- 
ward and unsteady. On measuring the femur, I found it an inch and 
a half longer than the opposite bone. A student of the hospital observ- 
ing this case, was reminded that in his own person he had suffered much 
inconvenience in walking from an inequality in the length of his limbs? 
which he had attributed to obliquity in the position of his pelvis. He 
had suffered many small exfoliations from one tibia, which had become 
very gradually hypertrophied in thickness, and on measuring this tibia, 
he now found it an inch longer than the opposite bone. He had re- 
lieved himself in some degree from the inconvenience in walking, by 
wearing on the sound limb a shoe having a thick sole and a very high 
heel. 

There are instances of circumscribed hypertrophy or outgrowths of 
bone, giving rise to tumors of the character of genuine exostoses, but 
differing from them in having no primordial structure of cartilage or 
fibrous tissue. Most of these circumscribed hypertrophies of bone are 
situated at the insertions of tendons. Other osseous growths are of the 
same character as these : such is the spiculum, which, after amputation, 
often arises from the end of the bone of the stump : such also are the 
irregular masses of bone often growing from the bodies of the dorsal and 
lumbar vertebrae, and less frequently from the bodies of the cervical 
vertebrae, in advanced life. It seems certain, moreover, that some of 
the osseous tumors which project from the outer surfaces of bones, but 
have originated in their interior cancellous texture, are of the character 



AND ATROPHY OF BONE. 29 

of these outgrowths or circumscribed hypertrophies of bone, and, ac- 
cordingly, that they are not preceded by the formation of cartilage 
or fibrous tissue. 

ATROPHY OF BONE. 

Bones become lessened in size by the diminution of their healthy 
tissue. The first distinct notice of an atrophied bone was probably by 
€hesselden, in the case of a soldier, who, at the siege of Gibraltar, re- 
ceived a wound in the groin, which disabled his limb for the rest of his 
life ; and on examining the femur, after his death, it was found to be 
one third smaller in its dimensionsthan the femur of the uninjured 
limb.* 

Atrophied bone is, in some instances, simply diminished in size ; in 
others its walls are thinned, and its cells widened ; and, occasionally, 
the cancellous texture wholly disappears, and the bone after maceration 
presents the characters of the bone of a bird, with its simple tube and 
thin walls. 

An impoverished condition of the body, from defective nutrition, is 
accompanied by atrophy of the bones, which, from the thinness of their 
walls and widening of their cells, are then readily broken by the slightest 
force, often by muscular action alone. Another cause of the atrophy of 
bone is the interruption of its due supply of blood. Thus Mr. Curling 
observed, that in the portion of a fractured bone deprived of blood from 
the medullary artery, the walls become thin, and the cells widened ; 
such, therefore, is the condition of the lower part of a femur or tibia 
fractured below the entrance of the medullary artery, whilst in the hu- 
merus the upper portion becomes atrophied when the fracture has oc- 
curred above the entrance of the medullary artery. f 

Want of action is followed by atrophy of bone : thus the bones of a 
paralytic limb diminish with the wasting of its muscles ; and, in like 
manner, anchylosis of the shoulder-joint is followed by atrophy of the 
humerus, and anchylosis of the hip-joint by atrophy of the femur. Also, 
after amputation, the bone of a stump which has been little used, be- 
comes lessened in size, with thinning of its walls, and the disappear- 
ance of its cells ; in short, under any circumstances of suspended or 
even diminished action, atrophy of bone ensues as remarkably as from 
the more direct defects of nutrition. 

* Anatomy of the bones. By William Cheselden. Fol. Tab. L. 
t On Atrophy of Bone. By T. B. Curling. Medico- Chirurgical Transactions, Vol. 
xx. 

3* 



30 ON HYPERTROPHY 

Bone atrophied from inaction becomes soft in its texture ; hence the 
bones of a joint which has been long diseased are often found so soft 
that they can be readily penetrated by a scalpel. The softening of 
bone under such circumstances is probably not from diminution of the 
-earthy matter, but from a change hi the arrangement and mode of 
connexion of its constituent parts : such certainly would be the conclu- 
sion from the observations of Dr. Stark, showing that in all bones, not- 
withstanding the differences in their hardness, the actual proportions of 
their animal and earthy constituents are nearly the same.* 

When atrophy of bone occurs in early life, it is often accompanied 
by the failure of its growth ; thus the bones of a joint which has been 
anchylosed since childhood are found atrophied in texture, and of small 
size, in consequence of their not having grown with the rest of the bo- 
dy. In the following case, failure in the growth of the lower jaw was 
the consequence of its articulation with the temporal bone becom- 
ing fixed. A child at the age of two years suffered an attack of 
inflammation in the brain, accompanied by convulsions, during 
which the lower jaw became immoveably fixed, with the mouth closed ; 
;and in this condition it remained. At the age of ten years, when the 
rest of the face had attained its full development, the lower jaw, still 
motionless, had not grown ; it remained of the size it was at the age 
of two years, and a very remarkable deformity of the face was thus 
produced. I have seen several instances in adults of the same deform- 
ity of the face, consequent on the lower jaw having remained of the 
size it was hi childhood, when it became immoveably fixed ; and, in 
these cases, the cause of the mischief had been the destruction of the 
soft parts around the jaws from excessive salivation. 

Disease in a bone occurring in early life is, in some instances, follow- 
ed by the interruption of its growth ; thus, in a child, the formation of 
an abscess upon the upper part of the tibia, accompanied by a partial 
separation of its epiphysis, was followed by so slow a growth of the ti- 
bia, that, several years afterwards, it was found to be an inch and a 
half shorter than the tibia of the opposite limb. Rickets in any of the 
bones of the limbs is also very commonly accompanied by arrest of 
growth, especially in the direction of their length. 

But there is, also, a class of cases, of not unfrequent occurrence, in 
which, without previous disease, or accompanying rachitic affection, or, 
indeed, any apparent cause, the growth of a single bone, or of all the 

* Edinburgh Medical and Surgical Journal, April, 1845. 



AND ATROPHY OF BONE. 31 

bones, of a limb is checked, so that the limb never attains its proper 
length. And when this defect of growth occurs in one of the lower 
limbs, progression is interfered with, and lameness of an ambiguous 
character often produced, which has been supposed to arise from dis- 
ease in the hip-joint. Among the consequences of such defective 
growth in any of the bones of one of the lower limbs, is the formation 
of a lateral curve of the spine. And in some among this series of 
cases, the shortness of the tibia has given rise to lameness, accompa- 
nied by permanent elevation of the heel, constituting talipes equinus, 
requiring the section of the tendo Achilles, which, in such instances, 
is performed with the best results ; for, by a proper management of 
the lhnb after the operation, the heel can be made to rest firmly and 
easily on the ground, without the slightest diminution of power in the 
muscles of the calf of the leg. 



CHAPTER II. 



NEURALGIA OF BONE. 

By this term I venture to designate a class of cases in which pain 
arises in a bone, severe and lasting, unaccompanied by inflammation or 
other organic change in its tissue, and thus, apparently, constituting 
a nervous affection of bone, like the neuralgia of other structures. 

Such cases occur, as might be expected, mostly in females ; and the 
pain in the bone is often accompanied by other symptoms of hysteria. 
in the instances of this seeming nervous affection of bone which I have 
met with, it occurred in the shaft, but more frequently in the condyles, 
of the femur, in the head of the tibia, and in the humerus. In some 
of the cases, a severe blow on the part preceded the attack of pain in 
the bone. In some cases the pain was limited to a small extent of 
the bone ; but in others, the pain extended through the whole of it. 
Compression of the limb aggravated the pain. There was scarcely 
any increase of heat in the soft parts covering the bone which was the 
seat of pain, and no more swelling than was occasioned by slight se- 
rous effusion into, or thickening of, the subcutaneous cellular tissue. 

Local depletory remedies, sedative applications, counter-irritants, all 
have obtained only a brief mitigation of the pain ; nor have constitu- 
tional remedies been more effective, with the exception of opium, which 
subdued the pain so long as the system was under its influence. The 
general health has not suffered in these cases more than might be ex- 
pected from the severity and duration of the pain. 

Such have been the principal features of this affection of bone ; but 
they do not belong to it exclusively. Inflammation of the substance 
of the bone and the circumscribed abscess in it, especially the latter, 
are often accompanied by symptoms, so closely simulating those of the 
simple neuralgic affection, as to render the diagnosis between them 
difficult ; yet it is a diagnosis of importance, on account of the opera- 



NEURALGIA OF BONE. 33 

tive proceedings which are required for the discharge of matter from 
the bone in the case of circumscribed abscess, but which, in an instance 
of simple inflammation, or of the neuralgic affection of bone, would be 
not merely useless, but probably occasion serious mischief. 

When the neuralgic affection in bone has been severe and of long 
continuance, there is evidence to show it may be followed by derange- 
ment of the vascular tissue of the bone, to the degree of producing 
sanguineous congestion, and even effusion of blood into it. Thus, in 
one case, after the long continuance of acute pain in the condyles of 
the femur, the limb being amputated, the only change found in the bone 
was a preternatural vascularity of its cancellous tissue ; and in another 
case, with a similar history, the limb being amputated, I found red 
patches, of the character of ecchymosis, in the cancellous texture of 
the Condyles of the femur and of the head of the tibia, which had been 
the seat of pain. 

The diagnosis between the neuralgic affection and inflammation of 
bone must chiefly rest on the following circumstances : first, the charac- 
ter of the constitutional symptoms, as these are, or are not, such as 
would afford ground for suspecting the local affection to be of a nervous 
or hysteric nature ; secondly, the character of the local symptoms, and 
the influence of remedies upon them. The pain attendant on inflam- 
mation of bone is usually less severe than the pain of its neuralgic af- 
fection ; it is rather a constant aching in the bone, than the paroxysms 
of severe pain, which occur in the neuralgic affection. Moreover, it is 
to be observed that local remedies do, although slowly, produce their 
effect on inflamed bone ; they obtain more than a mitigation of the pain ; 
when perseveringly used, they will wholly remove it. Not so in the 
neuralgic affections, for here the best of remedies obtained but a tem- 
porary and partial relief. 

The following are examples of the neuralgic affection of bone. 

Neuralgia of the Femur. A female, aged 29, was admitted into 
St. Bartholomew's Hospital in September, 1834, on account of severe 
pain in the inner condyle of the femur, accompanied by some swelling 
and tenderness, and a slight hicrease in the temperature of the soft 
parts covering it. She stated that, six months previously, she fell and 
struck the fore part of the knee ; that the pain in the bone commenced 
five weeks before her admission ; that it had been at times most severe. 
She was of a spare habit, and there was no more disturbance of the 
general health than might be ascribed to the suffering she had endured. 
Perfect rest of the limb, with the repeated application of leeches, pro- 



34 NEURALGIA OF BONE- 

duced no decided benefit. Two issues were made, one close to the 
seat of pain, the other at a little distance from it, but they were of no 
avail. Opium controlled the pain, but only so long as the system was 
under its influence. Mercury was administered to the extent of saliva- 
tion, and apparently with benefit, but it was of short duration. The 
general health now declined ; pain extended up the thigh and down the 
leg ; and occasionally, pain was felt in the other thigh, from which cir- 
cumstance it was suspected that the whole disorder might be of a neu- 
ralgic character. Under this impression the extract of belladonna was 
applied to the knee, but it was invariably followed by increase of the 
pain. The swelling upon the inner condyle was increasing, by the ef- 
fusion of serum into the subcutaneous cellular tissue. At this period 
of the case, it was thought that sufficient ground existed for believing 
that matter was confined within the bone to justify the perforation of it, 
but the patient would not assent to the operation. Iodide of potassium 
was given next, in doses, first of five, afterwards of eight, grains twice 
a day. During the use of this remedy, the pain in the bone very gra- 
dually diminished, but it afterwards recurred many times. Eventually 
the limb became perfectly sound. 

In this case, the cessation of the pain in the bone, during the admin- 
istration of the iodide of potassium, might be thought to indicate that 
the disease was inflammation of the periosteum or of the bone ; but the 
character of the constitution, and of the local symptoms, and the pro- 
gress of the disorder, were strongly in favour of its neuralgic nature. 

The following narrative was drawn up by Mr. Bayntin, who was in 
constant attendance upon the patient. 

Neuralgia of the Femur. " A lady, aged twenty-nine, in descend- 
ing a winding staircase, fell and severely bruised her left hip ; tender- 
ness of the part ensued, which in a few days completely subsided. In 
the course of tthe following month she began to suffer pain in the mid- 
dle and front of the thigh of the same side, and it was referred to the 
bone. The pain gradually increased ; and while at first it occurred 
in paroxysms lasting a few hours, it had lately become constant, and 
most severe. Compression of the thigh aggravated the pain, but not 
until it was sufficient to affect the deep parts of the limb. There was 
no increased heat, swelling, or other sign of inflammatory action in the 
soft parts around the femur. The tongue was clean and the pulse tran- 
quil. Mercury, opium, iodine, and quinine, were perse veringly em- 
ployed until each had produced its full effect on the system. Every 
variety of local application was tried, but upon the pain in the thigh 



NEURALGIA OF BONE. 35 

the best of the remedies had only a temporary effect. The case was re- 
peatedly seen by Mr. Stanley ; it also received the benefit of Mr. Bli- 
zard's and Mr. Lawrence's attention. Throughout there was appre- 
hension of organic disease, commencing either in the periosteum or 
bone, with a suspicion, however, that it might be a neuralgic affection 
without change of structure in one or other part. At length, after the 
endurance of severe suffering above three months it began to remit, and 
by degrees the remissions were for a longer period and more complete. 
In this way the case proceeded slowly towards a complete recovery. 
Nothing occurred to explain the cause of the pain in the femur, nor 
could the removal of it be ascribed to any of the various remedies 
employed." 

Neuralgia of the Tibia. A female, aged twenty, of slender frame, 
stated that her left knee, she knew not why, swelled, became painful 
and contracted. Through the four following years, as a patient in sev- 
eral metropolitan hospitals, and in attendance on various dispensaries, 
every variety of treatment had been repeatedly applied to the joint, 
and at one period it recovered sufficiently to enable her to walk without 
inconvenience ; but a few months afterwards pain and swelling return- 
ed in the knee with increased severity, and continued to the period of 
her admission into St. Bartholomew's Hospital, when the following was 
the condition of the joint, — it was immoveably fixed in the bent posi- 
tion, the pain in it was acute, but more so on the inner side of the head 
of the tibia, where the soft tissues covering the bone were slightly thick- 
ened. From the history and present circumstances of the case, I could 
not but apprehend disease in the joint ; and from the fixedness of the 
pain in the head of the tibia, with the thickening of its coverings, it 
was thought that this might be the seat either of abscess, or of necrosis 
in a portion of its cancellous texture. Her general health was extreme-, 
ly feeble, with total failure of appetite, and absence of sleep except 
from the influence of strong opiates. Her constitution appeared to be 
sinking, and consequently it became necessary to consider the proprie- 
ty of removing the limb. A consultation was held on the case, at 
which the principal question apparently requiring consideration was, 
whether the hmb should be removed, or the head of the tibia perforat- 
ed in the expectation of finding matter or dead bone within it ; and the 
decision was that the limb should be removed. This was accordingly 
done, and, on examining the joint, several dark patches were found in 
the cancellous texture of the condyles of the femur, and of the head 



36 NEUKALGIA OF BONE. 

of the tibia, presenting however rather the character of ecchymoses 
than of inflammation of the bone ; there had been, besides, partial 
absorption of the articular cartilage upon the condyles of the ferum ; 
but from the appearances of a part I inferred that this removal of the 
cartilage was nothing more than the effect of the undue pressure it had 
received in the contracted and rigid state of the joint. 



CHAPTER III 



INFLAMMATION OF BONE. 

In the healthy organization of bone provision is made for the free 
circulation of blood through its tissue by the large diameter of its vas- 
cular canals ; and it is by the dilatation of the vessels within these ca- 
nals that inflamed bone becomes of a red colour. In a young person, 
from the front of whose tibia the skin aud periosteum had been detach- 
ed by violence, the exposed bone was first of a pale rose tint, and af- 
terwards of a deep red colour, when its substance had become inflam- 
ed. The excessive vascularity of inflamed bone is observed in cases of 
necrosis, where perforations of the living bone are made for the remov- 
al of dead bone ; for, in such operations, blood is often seen flowing 
from the cut surface of inflamed bone as freely as from inflamed mus- 
cle or other very vascular soft tissue. 

Increase in the sensibility of inflamed bone is not less marked than 
the increase of its vascularity. When, in operations, inflamed bone is 
perforated or divided, the pain is severe ; and the granulations which 
arise from inflamed bone participate in the morbid sensibility of its 
tissue. 

From the inflamed tissue of bone there are products corresponding 
with the albuminous products from the inflamed tissues of soft parts. 
It may be that pus is produced from the inflamed compact osseous tis- 
sue. Into the inflamed cancellous tissue pus is certainly deposited ; 
the source of it here, probably, is the fine and very vascular membrane 
which lines the cells of bone. 

It results from the intimate connexion which, in respect to their vas- 
cular and nervous endowments, the component parts of a bone hold one 
with another, that they readily reciprocate their morbid actions ; not, 
however, hi an irregular manner, for there is an order observable in the 
progress of inflammatory changes from one part of a bone to another. 
Inflammation of the medullary membrane is followed by inflammation 

4 



38 INFLAMMATION OF BONE. 

in the periosteum and outside of the bone. Moderate inflammation of 
the medullary membrane is followed by thickening of the periosteum, 
and by osseous deposits on the surface of the bone, with expansion and 
thickening of its outer lamellae. Acute inflammation of the medullary 
membrane is followed by ulceration of the periosteum, by suppuration 
beneath it, and by ulceration of the surface of the bone. Inflammation 
of the periosteum is followed by thickening of the inner lamellae of the 
bone. 

Enlargement of bone is the general effect of inflammation in its tis- 
sue. But its characters vary with the circumstances giving rise to the 
inflammation ; and it may be accompanied by the expansion or indura- 
tion of the bone, or by osseous deposits upon its surface. 

ENLARGEMENT OF BONE BY EXPANSION OF ITS TISSUE. 

The expansion of the tissue of bone is, in some respects, analogous 
to the inflammatory swelling of soft parts. More than twenty years 
ago, I had the first distinct view of this change in the bones of an elbow- 
joint, from a boy ten years of age, whose arm was amputated by Mr. 
Abernethey. These bones were preserved in the museum of St. Bar- 
tholomew's Hospital* ; and I have been accustomed to exhibit them in 
my lectures as an example of the pathological fact in question. Re- 
cently, in a more extended view of these morbid processes, when en- 
gaged with Mr. Paget in the examination of the vast series of diseased 
bones in the Museum of the College of Surgeons, I have learned that 
the simple swelling of bone, from expansion of its tissue, is one of the 
most frequent alterations to which it is liable. 

In the swollen or expanded bone its lamellae are separated, its vascu- 
lar canals widened, and its cells enlarged. By these changes the bone 
is softened, not that its lamellae and the walls of its cells are thinner 
than naturally, but that by their separation and the widening of their 
interspaces, the bone loses so much of its compactness and power of 
resistance that it readily yields to compression. The liberality of Mr. 
Arnott, of University College Hospital, has furnished me with some 
striking illustrations of this condition of the bone, obtained from a case 
in which, on account of disease in the elbow-joint, excision of the ends 
of the bones had been performed. Inflammation ensued in the re- 
maining portion of the humerus, accompanied by severe constitutional 

* First series, No. 56 ; Plate I, figs. 2, 3. 



INFLAMMATION OF BONE. 39 

derangement, which terminated fatally. The inflamed bone was of a 
deep red colour, and considerably enlarged by the expansion of its 
tissue*. 

The enlargement of bone by expansion occurs in its compact and in 
its cancellous tissue. I have seen many instances of expansion of the 
articular ends of bones, especially of the inner condyle of the femur 
and of the head of the tibia, ensuing from a blow or other slight inju- 
ry. The gradual enlargement of the bone was accompanied by ten- 
derness in the part, by a slight increase of its heat, but by no change 
in the soft coverings. Local depletory remedies and counter-irritants 
were in such cases effective in restoring the part to a natural condition, 
as far as its sensations were concerned ; but, as in other affections of 
bone,* the morbid action very often recurred, and I have not in any in- 
stance clearly recognized a diminution of the enlarged bone. I be- 
lieve that a bone once enlarged by the expansion of its tissue will per- 
manently remain so. 

ENLARGEMENT OF BONE WITH INDURATION OF ITS TISSUE. 

The enlargement of bone with induration is the effect of prolonged 
inflammation in its tissue ; and, according to the observation of Mr. 
Paget, it appears that the lamellae of the inflamed bone are first sepa- 
rated and its cells widened ; and that the lamellae become thickened, 
hardened, and consolidated together. As, in the original formation of 
bone, its solidity is owing to the formation of osseous concentric laminae 
upon the insides of the Haversian canals, so, in disease, its induration 
is the effect of increased osseous formation within these canals, narrow- 
ing some of them and obliterating others. Accordingly, indurated 
bone is less vascular and less oily than healthy bone, and in the micros- 
cope its vascular canals are found to be few and of small size. 

The enlargement and induration of bone may occur in its compact 
or in its cancellous tissue, and either in the whole bone or exclusively 
in its outer or inner lamellae. When the inner lamellae of a long bone 
become separatod from each other, and are thickened and indurated, 
they arch inwards, so as to encroach upon the medullary tube, often to 
the extent of obliterating it. 

The degree of induration in bone is probably proportionate to the 
duration of inflammation in its tissue. In its extreme degree, the bones 
acquire the hardness and compactness of ivory, and these changes are 

* Plate l,figs. 4, 5, 6. 



40 INFLAMMATION IN BONE. 

accompanied by proportionate increase of their weight. A skull in 
the Museum of St. Bartholomew's Hospital, the bones of which are 
very thick and hard, weighs, without the lower jaw, three pounds three 
ounces ; the heaviest of three healthy skulls weighing one pound four- 
teen ounces. 

Local injury is occasionally the cause of enlargement and induration 
of bone ; thus, a blow upon the shin may be followed by the enlarge- 
ment of the tibia ; and I have known instances where a blow upon the 
head was followed by thickening with induration in the bones of the 
cranium. But these conditions of bone are mostly the effect of rheu- 
matism ; and accordingly, in hospital practice, the instances of them 
are very numerous in one or more of the long bones in both sexes, but 
particularly in those who in their occupations have been much exposed 
to the influences of cold and moisture. 

Pathological museums abound in examples of long bones, the shafts 
of which are misshapen, enlarged, and indurated, more especially the 
femora and tibiae, less frequently the bones of the upper limbs. In 
most instances the morbid changes are symmetrical ; the two femora or 
two tibiae being enlarged equally, and so exactly alike in every other 
particular, that without any knowledge of their history, we confidently 
pronounce the symmetrically diseased bones to have belonged to the 
same person. 

In several instances I have been able to ascertain, that the individu- 
als in whom these conditions of the bones existed, had suffered in their 
limbs the long-enduring, or many times recurring, attacks of rheumatic 
inflammation. One old man, all of whose long bones in the upper and 
lower limbs I found greatly enlarged, told me, that for many years he 
had scarcely ever been free from rheumatic pains. Another patient, a 
female, thirty-five years of age, whose femora and tibiae were greatly 
enlarged, stated, that at the age of fifteen she suffered an attack of 
rheumatic fever, since which the pains in her bones had never com- 
pletely left her. I had the opportunity of observing the whole course 
of the disease in a boy fourteen years of age, who was admitted into 
St. Bartholomew's Hospital when suffering acute inflammation in three 
large joints simultaneously, the hip, knee, and ancle of the same limb. 
Upon the subsidence of the inflammatory affection of the joints, in- 
flammation ensued in the periosteum of the femora and tibiae, followed 
by suppuration beneath the periosteum, and by gradual enlargement of 
the shafts of the bones. During several months whilst the bones were 
enlarging the general health of the boy was very feeble, but it was as- 



INFLAMMATION OP BONE. 41 

certained that his urine contained its ordinary healthy constituents. In 
other cases I have been interested in observing, that on the occasions 
of exposure to extreme variations of temperature, especially from heat 
to cold and moisture, fresh paroxysms of irritation have arisen in the 
diseased bones, accompanied by much pain in them and tenderness in 
the periosteum ; each paroxysm subsiding under the influence of iodide 
of potassium, but with an increase in the size of the bone. 

From long enduring rheumatic inflammation in any of the large 
joints, more especially in the hip, the cartilages are absorbed, and the 
bones become indurated, enlarged, and altered in their form, probably 
from the pressure they have received in an early stage of the disease 
when their texture was softened by inflammation ; thus the head of the 
femur becomes broad and flattened, and of irregular figure, with cor- 
responding changes in the acetabulum. With induration of the artic- 
ular ends of bones, their surfaces, when deprived of cartilage, become 
smooth and polished, with a porcellaneous appearance, owing to the 
Haversian canals becoming filled with earthy substance*. 

Upon enlarged and indurated bone medicines have no effect : its con- 
dition will be permanent. Individuals, in whom these changes have 
occurred in the long bones, are doomed for the rest of fife to the dis- 
comfort of dragging about their misshapen and heavy limbs, thus pre- 
senting another to the catalogue of miseries to which rheumatism gives 
rise. But against the tenderness and irritation of the periosteum, 
which precede and accompany the morbid changes in the bones, treat- 
ment may be directed with the best effect, particularly the local appli- 
cation of mercury to the limb, with the administration of iodide of po- 
tassium and sarsaparilla. 

ENLARGEMENT OF BONE BY OSSEOUS DEPOSITS ON ITS SURFACE. 

Such an enlargement of bone is the consequence of inflammation in 
its periosteum. The following is the mode of its occurrence, — gelatin- 
ous substance is deposited on the surface of the bone, and becomes car- 
tilaginous and then osseous. A thin layer of osseous substance is thus 
formed between the periosteum and the bone, to both of which it is 
united by vessels. At first, the osseous layer may be readily peeled 
off from the bone, but afterwards is inseparably united to it. As the 
osseous deposits increase, they assume such an irregular form, that 

* Microscopic observations, by Mr. Quekett, of the Royal College of Surgeons. 

4* 



42 INFLAMMATION OF BONE. 

they may be represented as rock-like masses of osseous substance, pro- 
jecting from the bone and enlarging it. 

Rheumatic inflammation of the periosteum is probably the most fre- 
quent cause of these osseous deposits upon the surface of bones ; but 
they occur under other circumstances. For instance, in the skulls of 
young females who have died whilst pregnant, or shortly after parturi- 
tion, such osseous deposits have been found upon both the outside and 
the inside of the skull, but more especially in the latter situation. The 
successive stages in the formation of these deposits have been distinct- 
ly traced ; consisting, first, in a vascular exudation from the surface of 
the skull, which changes into cartilage, and then osseous substance is 
mixed with the cartilage in the form of dense lamellae and spicula, 
which are firmly united to the skull. Although the occurrence of this 
disease appears to have a close relation with the pregnant and puerpe- 
ral states, it is not preceded or followed by any peculiar or distinctive 
symptoms*. 

The diagnosis of these various enlargements of bone cannot always 
be made during life ; nor is this practically of consequence : it is suffi- 
cient to know that inflammation in bone occasions its enlargement, either 
by simple expansion or with induration, and that inflammation of peri- 
osteum occasions the enlargement of bone by osseous deposits on its 
surface. Further, in respect to the action of particular diseases, it is 
to be observed, that whilst rheumatic inflammation occasions general 
enlargement of the shafts of bones, syphilitic inflammation in perioste- 
um gives rise to circumscribed swellings of the bones, or nodes. These 
several forms of disease may all be found in the several bones of the 
same individual. Of this a remarkable instance occurred in a Negro, 
a patient in St. Bartholomew's Hospital. He had suffered from syphi- 
lis, and besides severely from rheumatism, the consequence of exposure 
to cold and moisture in the streets of London, in which for a long time 
he had almost wholly lived. Some of his long bones were found sim- 
ply expanded, others expanded and indurated, and others, especially 
the tibiae and fibulae, and the bones of his hands and feet were found 
irregularly enlarged by osseous deposits on their surface, from the rheu- 
matic inflammation of which their periosteum had long been the seatf . 

It is remarkable, that whilst the pericranium, in its structure and re- 
lations to the cranium, differs in no respect from periosteum in its rela- 

* Rokitansky ; Pathologische Anatomie, Bd. ii., p. 237. There is also a memoir on 
this subject by M, Ducrest, Memoirs de la Societe Medicale d'Emulation de Paris. T. ii. 
1 Museum of St. Bartholomew's Hospital. 



INFLAMMATION OF BONE. 43 

tions to other bones, yet that from the pericranium osseous deposits 
probably never arise*. Accordingly, the cranial bones are not found 
enlarged by osseous deposits on their outer surfaces ; their enlarge- 
ment is mostly the effect of expansion with induration of their texture, 
but is, in some rare instances, the effect of osseous deposits on their 
internal surfaces. 

Enlargement of the bones of the skull is frequently coincident with 
local or general nervous affections ; but in such cases it is, in general, 
difficult to determine, whether the nervous affection holds the relation 
of cause or effect to the altered structure of the bones. The charac- 
ter of the nervous affection varies in different instances, probably in 
accordance with the predisposition of the individual. Thus, in some 
cases, enlargements of the skull have been accompanied by insanity ; 
in others, by epilepsy ; and in others, by local nervous symptoms, of 
the character of tic douloureux. Dr. Greding, physician to a hospital 
at Waldheim, receiving a large number of lunatics and demented per- 
sons, has recorded, that of two hundred and sixteen cases, including 
those of madmen, idiots, and epileptics, the skull was found unusually 
thick in one hundred and sixty-seven ; but that in many of the remain- 
der the skull was unusually thin. Other inquirers have reported the 
number of cases of insanity, accompanied by disease in the skull to be 
proportionately less considerable-)*. Dr. Bright has recorded cases of 
epilepsy, in which the bones of the skull were found much increased in 
thickness and density:]: : and there are on record some remarkable cases 
of tic douloureux having its seat in the nerves of the face, accompani- 
ed by osseous growth or other source of irritation in the bones contigu- 
ous to the affected nerves§. But it is certain, that in the generality 
of cases of tic douloureux no accompanying change of structure can be 
any where discovered. I am acquainted with two cases, in which tic 
douloureux had long existed in the supra- and infra-orbitar nerves, and 
in which not the slightest deviation from healthy structure was detected 
in the most careful examination of the affected nerves, and of the parts 
connected with them. 

* The osseous deposits which, in rare instances, .have heen found on the exterior of 
the skulls of females who died when pregnant, or during the puerperal state, .are but an 
apparent exception to this statement ; for here the exudation is from the skull, not from 
the pericranium. 

t Pritchard on Insanity. Results of necroscopical researches into the changes of 
structure connected with Insanity, p. 209. 

X Medical Reports, Vol. ii. 

§ Essays and Observations, by Sir Henry Halford. 



44 INFLAMMATION OF BONE. 

GENERAL CONSIDERATIONS ON THE TREATMENT OF INFLAMMATION 

IN BONE. 

Inflammation of bone is to be treated according to the same princi- 
ples as inflammation of other structures ; but, with respect to the selec- 
tion of remedies, the mode of using them, and the influence they are 
likely to have on the morbid processes in bone, there are circumstances 
to be mentioned. 

Bone is not readily impressed by external agents : its organic chan- 
ges in health and in disease being of slow progress, the remedies which 
influence them are proportionately slow in their operation. But, not- 
withstanding the little susceptibility bone possesses, its nervous and vas- 
cular endowments are so far in harmony with the rest of the system, 
that when the nervous system is unquiet, and the digestive organs are 
deranged, the disease of bone, like the diseases of soft parts under the 
same circumstances, are with difficulty controlled. 

To subdue acute inflammation in bone, especially when seated in the 
medullary membrane of a long bone, the requisite measures are deple- 
tion and medicines adapted to repress vascular action and subdue pain. 
An acute and persisting pain in the centre of a long bone, quickly fol- 
lowed by fever and excitement of the nervous system, are sufficient to 
warrant apprehension that the medullary membrane is the seat of in- 
flammation, and to call for activity of treatment ; for it is most impor- 
tant the disease should be arrested before it advances to the stage of 
suppuration in the bone, by which the limb and even the life of the pa- 
tient is likely to be endangered. 

The local remedies for subduing inflammation in bone are, abstrac- 
tion of blood from the surrounding soft parts, with fomentations, warm 
poultices, or cold lotions, as the feelings of the patient may indicate. 
That these remedies may produce their full effect, it is necessary that 
the diseased part be in a state of perfect rest, and that its position be 
such as will not favour the congestion of blood in its vessels. Another 
local remedy of much value for subduing inflammation in bone, is mer- 
curial ointment constantly and plentifully applied to the surrounding 
soft parts. 

There is, besides, an internal remedy, which never fails to assist in 
the removal of inflammation from bone. This is iodide of potassium. 
There have been differences of opinion respecting the most effective 
dose of this remedy. My experience is in favour of its administration 



INFLAMMATION OF BONE. 45 

in small doses ; for I have not observed, that, when given in large 
doses, it has more rapidly, or with more certainty, cured the disease. 
The dose which I ordinarily direct is either two or three grains, three 
times a day, in camphor mixture or in a bitter vegetable infusion, and 
in conjunction with sarsaparilla, when, with the disease in the bone, the 
vital powers are at the same time feeble and depressed. 

It is probably true, that iodide of potassium has the most distinct 
and best marked influence upon the inflammation of membranous struc- 
tures ; and, accordingly, that its remedial effects will be greatest when 
the seat of inflammation is the periosteum or medullary membrane, 
rather than the osseous tissue. But the inflammatory action, whatever 
was its original seat, soon spreads through the entire bone ; therefore 
iodide of potassium is the remedy for inflammation in bone under all the 
circumstances of its occurrence. 

My experience of the use of iodide of potassium in the syphilitic af- 
fections of bone, agrees with the records on this subject by Martin 
Hassing, of Copenhagen*, who states, that, " in no other symptom of 
syphilis is the iodide so efficacious, and its effects so certain as in these 
cases of pains in the osseous system, whether they occur by night or 
day, or have troubled the patient for years, or only for a few days ;" 
and he subjoins a statistical account of seventy-three cases of pains of 
the bones treated by iodide of potassium, in sixty-five of which the 
pains wholly disappeared, while in three they were diminished, and in 
five the iodide was given without effect. And here it is but justice to 
the memory of Dr. Williams, physician to St. Thomas's Hospital, to 
acknowledge the great service he rendered to medicine, in having been 
the first to notice the influence of iodide of potassium as a remedy in 
secondary syphilisf. 

In the acute affections of bone, when seated in the medullary mem- 
brane, it is expedient, with the employment of mercury as a local ap- 
plication to the surrounding soft parts, to administer it internally, in the 
view of producing its full influence upon the system. Calomel and 
opium are well suited for this purpose ; and of the power which the con- 
stitutional action of mercury has to arrest acute inflammation in bone I 
am well assured by experience. But it must be admitted, that these 
acute affections of bone, requiring active mercurial treatment, are rare 

* British and Foreign Medical Review, October, 1845. 

t The first notice of this subject, by Dr, Williams, Avas in a paper read at the Col- 
lege of Physicians in 1834, and it is fully treated in his Elements of Medicine, 2 vols. 
8vo. 1836—1841. 



46 INFLAMMATION OF BONE. 

by comparison with the less acute and long-enduring affections of bone, 
for which iodide of potassium is the suitable and almost invariably ef- 
fective remedy. 

When there has been long-enduring, or often repeated inflammatory 
action in bone, counter-irritation, established in the parts adjacent to the 
seat of pain, is often useful. But, for the good which the counter-irri- 
tant can effect, it must be kept in full activity ; if it is allowed to be- 
come indolent, the pain in the bone will quickly recur. And it is to be 
understood, that counter-irritation is applicable to all the painful en- 
largements, indurations, and thickenings of bone, which other remedies 
have failed to relieve. I am sure that I have, by counter-irritation, 
obtained the perfect quietude of many such enlargements of the artic- 
ular portions of bones. In illustration of the effect which a discharge 
from the surface of a limb may have in quieting the irritation of diseas- 
ed bone, I mention the case of a boy in Christ's Hospital, suffering 
from disease of the elbow-joint, at the time Mr. Abernethy was surgeon 
to the institution. Suddenly, and without apparent cause, the integu- 
ments covering the joint became extensively ulcerated ; this was re- 
garded by me as an aggravation of the disease ; but it was otherwise 
viewed by Mr. Abernethy, and rightly so, for the ulceration on the sur- 
face of the joint operated as a natural issue, in relieving the irritation 
of the diseased bones ; directly the integuments ulcerated, the pain in 
the joint subsided. 

The use of counter-irritation in the treatment of the diseases of bone 
is to be regulated by the following considerations. It is not to be em- 
ployed whilst the inflammatory processes in the soft parts around the 
diseased bone are active ; nor until they have sufficiently subsided to 
allow the issue or seton to be placed near enough to the diseased bone 
to control the actions within it. The extent and the situation of the 
counter-irritant are to be determined by the degree of thickness of the 
soft parts covering the diseased bone. When the carpal or the tarsal 
bones are the seat of disease, a large issue placed directly over them 
will be likely, from the thinness of their investing soft parts, to aggra- 
vate the disease. When, on the other hand, the bones of the hip, or 
of the shoulder-joint, are the seat of disease, the thickness of their in- 
vesting soft parts permits the issue to be placed directly over them. 
The counter-irritant is to be regarded as a controllable disease estab- 
lished on the surface of the limb, in the hope that it will divert the ac- 
tivity of the organic processes from the diseased bone ; but that it may 
have this effect, care is to be taken that the new disease does not ex- 



INFLAMMATION OF BONE. 47 

tend its sphere of irritation to the old one. It is, moreover, inexpedi- 
ent to apply a counter-irritant in cases where there is much suppuration 
from the soft parts around the diseased bone : for here, provided the 
matter has a free outlet through the surrounding fistulous passages, the 
discharge issuing through these will afford all the relief to the irritation 
of the diseased bone that can be obtained by the artificial drain of an 
issue or seton. The cases which are most benefited by a counter-irri- 
tant are those in which the diseased bone is unaccompanied by abscess 
in the contiguous soft parts, or where the discharge through any fistu- 
lous passages that may lead to the diseased bone, is so trifling as to af- 
ford no adequate relief to the pain and irritation in the adjacent parts. 



CHAPTER IV. 



SUPPURATION IN BONE. 

Suppuration in bone is in some cases of small extent, and the 
matter is contained in a single round or oval cavity hollowed out of the 
substance of the bone. But in other instances the matter is diffused 
more or less extensively through the cancellous texture or medullary 
tube of the bone. Thus the abscess in bone is conveniently distin- 
guished into the circumscribed and diffused. 

The circumscribed abscess is mostly situated near to, or within, the 
articular ends of long bones ; but I have seen it in the middle of their 
shafts. The cavity in the bone is usually lined by a very vascular 
membrane, and around it the bone is hardened, also, in some instances, 
enlarged by the expansion of its texture. The periosteum and adja- 
cent cellular tissue covering this part of the bone are generally thick- 
ened. In some cases a narrow passage has formed in the osseous wall 
of the abscess, through which the matter has escaped from the interior 
of the bone. In this way the matter has passed from the abscess with- 
in the articular end of a bone into the adjacent joint ; and I have 
known several instances of destruction of the knee-joint consequent on 
the escape of matter into it : in some cases, from the articular end of 
the femur, and in others, from the head of the tibia ; and in one case, 
the abscess, which burst into the knee-joint, had formed within the can- 
cellous texture of the patella. 

In most cases, the circumscribed abscess in bone cannot be traced to 
local injury or other distinct cause. The symptoms which ensue from 
it are such as might be expected from the confinement of matter with- 
in the dense tissue of bone. Generally, at the seat of the disease, the 
Coverings of the bone are tender, a constant aching is felt in the bone, 
with paroxysms of acute pain and severe constitutional derangement. 
It is remarkable, that in some instances there has been a remission of 



SUPPURATION IN BONE. 49 

the symptoms so complete and for so long a period, that the patient 
has supposed himself to be well ; but the pain in the bone, from the 
confinement of matter within it, has returned. In one case I distinct- 
ly traced the remission of the symptoms to the formation of a passage 
in the wall of the abscess, permitting the escape of the matter from 
the interior of the bone into the parts around it. 

It is probable that, in some cases, a deposit of tubercle has preceded 
the circumscribed abscess in bone, and that the tuberculous matter, 
mixed with purulent fluid, has then passed out of the bone, leaving a 
cavity in the bone analogous to the tuberculous cavity in lung. Such 
appeared to have been the character of the disease, in instances where 
I found masses of tuberculous matter, mixed with purulent fluid, filling 
excavations in the articular ends of bones communicating with the ad- 
jacent joints. 

The circumscribed abscess in bone usually remains of small size, but: 
in some cases it has enlarged much beyond the natural limits of the 
bone. Such an enlargement of the abscess is not the effect of simple 
expansion of the walls of the bone ; for, in some of these cases, the 
osseous wall of the abscess has increased in thickness with the enlarge- 
ment of its cavity. The process is of a vital nature, consisting in the 
combined actions of absorption on the inside of the abscess, and of 
osseous deposit on its outside, whereby its osseous walls may acquire 
any degree of thickness, according to the predominance of absorption 
in the one direction, or of deposit in the other. Such an enlargement 
of the abscess is but the repetition of the natural process of growth, 
effecting the gradual enlargement of the medullary tube of a bone, 
proportionate to the increase of its circumference. In the museum of 
the Royal College of Surgeons in Edinburgh, there is an instance of a 
large osseous cyst originating in the head of the tibia, the walls of 
which are more than an inch in thickness. A circular aperture, about 
an inch in diameter, extends through the wall of the cyst, in which the 
patient used to introduce a wooden plug, and withdraw it to allow the 
escape of the matter on feeling pain from distension of the cyst. In 
this way, from sixteen to twenty-four ounces of purulent fluid were 
every day discharged from the cyst*. In the same museum there is 
an osseous cyst, probably originating in abscess, within the lower part 
of the femur, which is twenty inches in its circumference ; and in the 

* For the representation of this remarkable specimen! I am indebted to the late Pro- 
fessor Russell, of Edinburgh. Plate 6, figs. 1, 2. 

5 



50 SUPPURATION IN BONE. 

museum of St. Bartholomew's Hospital there is a sacrum, the walls of 
which are expanded into a cyst, which was filled with purulent fluid*. 

Diffuse suppuration through the cancellous and medullary tissue of 
a bone is usually a most formidable disease, leading to destruction of 
the bone and of the soft parts around it, with the most severe constitu- 
tional derangement. 

Local injury is in many instances the cause of diffuse suppuration 
through a bone ; thus, from a blow on the skull, suppuration has ensu- 
ed through its diploe ; and from a blow on the leg, suppuration has en_ 
sued through the medullary tube of the tibia. In one case, diffuse 
suppuration through the tibia occurred from long exposure of the limb 
to severe cold and moisture. There are also instances of diffuse sup- 
ration through the medullary tissue of long bones arising in the course 
of fever. Such appeared to be the nature of the following case. 
" The patient, about forty years of age, was seized with a fever, at- 
tended w h violent symptoms, and in about a fortnight a swelling sud- 
denly appeared upon the whole leg, accompanied by great inflammation 
and pain, and matter was discovered extending from the knee to the 
ancle ; upon the discharge of which, the bone was found carious in its 
whole length. Amputation of the limb was performed. Upon the ex- 
amination of it, the tibia was found filled with purulent fluidf ." 

When, after amputation, sloughing has ensued in the soft parts 
around the end of the bone, suppuration is often found extending some 
way within the medullary tube. Also, in compound fractures, suppura- 
tion frequently ensues within the medullary tube of the broken bone. 
In these instances, the inflammation usually appears to have extended 
from the soft parts into the bone ; but occasionally it is otherwise. Ei- 
ther after amputation, or in compound fractures, inflammation, followed 
by suppuration, has directly ensued in the medullary tissue of the bone. 
The following is an instance of it after amputation : — 

Diffuse Suppuration in the Femur. In a young, and apparently 
healthy, man, the thigh was amputated, by Mr. Abernethy, in its low- 
er third, on account of enlargement of the knee-joint, supposed to de- 
pend on thickening of its synovial membrane. A few days after the- 
operation, severe pain was felt deep in the thigh, and much constitu- 
tional disturbance arose, chiefly affecting the nervous system, which 
continued to his death, on the twenty-eighth day after the removal of 

* First Series, No. 28. f Gooch's Surgery. Vol. ii. 



SUPPURATION IN BONI5. 51 

the limb. On examining the knee, I found that the enlargement of 
the joint was produced by a mass of encephaloid substance originating 
within the condyles of the femur ; and in the stump I found the peri- 
osteum upon the remaining portion of the shaft, and upon the neck of 
the femur, very thick and vascular, and detached from the bone. The 
medullary tube of the shaft, and the cancellous tissue of the head and 
neck of the bone, were filled with purulent fluid. The medullary mem- 
brane was readily recognized by its thickness and vascularity. On re- 
moving the periosteum from the tibia, its surface was found mottled by 
effusions of blood into its substance, resembling the spots and blotches 
of purpura*. 

Similar cases to the foregoing are recorded by M. Reynaud, in a 
Memoir on Inflammation of the medullary tissue of the long bonesf. 
In some of these, suppuration in the medullary and cancellous tissue 
of the bone was combined with suppuration in the principal veins of the 
limb, and with purulent deposits in distant organs and cavities. Cru- 
veilhier, also, has reported, that in cases where there had been wounds 
of the scalp, he found purulent fluid in the veins ramifying through the 
diploe of the cranium, and purulent deposits in the lungs and liver. 
Cruveilhier considers it to be well established that phlebitis in the bones 
is one of the most frequent causes of visceral abscess succeeding to 
wounds, by accident or surgical operation, in which the bones are im- 
plicated ; and states that, during the year 1814, in nearly all the pa- 
tients at the Hotel Dieu who died after amputation, he found suppura- 
tion in the medullary tissue of the long bones J. In this country, Mr. 
Phillips, of the Westminster Hospital, has recorded observations to the 
same effect§ ; and Dr. Carswell has given some excellent representa- 
tions of suppuration in the medullary tissue of the femur combined 
with inflammation in the veins of the limb||. But, notwithstanding 
such an amount of evidence on the subject, it is nevertheless true that 
suppuration through the medullary tube of a bone after amputation is 
not a frequent occurrence. 

There have been instances in which suppuration through the medul- 
lary tube of a bone was, in an early stage of the disease, deprived of 

* Museum of St. Bartholomew's Hospital. First series, Nos. 46, 47, 48. Plate 18, 
figs. 3, 4. 

t Archives Gen. de Medecine. Juin, 1831. 

X Anatomie Pathologique, T. I., liv. xi., fol. 

4 Medical Gazette, Vol. xiii. 

II Illustrations of the elementary forms of disease. Fasciculus viii., plate 3. 



52 - SUPPURATION IN BONE. 

its usual severity and danger by the escape of the matter from the in- 
terior of the bone through ulcerated openings in its walls. Long per- 
sistence of pain in a bone, followed by the sudden remission of it on 
the appearance of an abscess in the adjacent soft parts, form the chief 
part of the history of such a case. But its features may not be readi- 
ly recognized ; it was so, at least, in the following instance. 

Suppuration in the medullary tube of the Humerus. A man was 
admitted into St. Bartholomew's Hospital, who stated, that for several 
months he had suffered pain in the bone of his arm, which had lately 
subsided on the appearance of a swelling in the adjacent soft parts. I 
found an abscess, in the upper third and inside of the arm, of the size 
of a walnut, and its cyst was so loose and circumscribed that it appear- 
ed to be wholly subcutaneous. Accordingly, it was not supposed to 
have any connexion with the bone, and the real nature of the disease 
was not suspected. But, after some time, rapidly destructive inflam- 
mation ensued in the elbow-joint, on account of which the arm was am- 
putated near the shoulder. On examining the humerus, I found its 
medullary tube filled with purulent fluid and lymph, and the medullary 
membrane much thickened. Minute ulcerated holes in the walls of 
the bone communicated with the abscess in the adjacent soft parts, 
and in the articular end of the bone there was an ulcerated channel 
through which the matter escaped from the medullary tube into the 
elbow-joint. 

Suppuration through the medullary tube of a bone is, in some cases, 
accompanied by necrosis of its walls. The evidence in such cases, 
that the mischief commenced in inflammation of the medullary mem- 
brane, would be the deposit of purulent fluid or lymph within the bone, 
which is not a character of necrosis arising under any other circum- 
stances. This point will be illustrated by the following case. 

Suppuration through the medullary tube of the Tibia, accompanied 
hy necrosis of its ivalls. A youth, eighteen years of age, was brought 
from the country to St. Bartholomew's Hospital, with the following his- 
tory of his case, — that six weeks previously he sprained his ancle, and 
on the following day had lain on the wet ground with a powerful sun 
shining on him. On the next day the whole leg became red, swollen, 
and painful. A few days afterwards, a large quantity of matter was 
discharged by incision near the ancle, and other openings for the same 
purpose were subsequently made near the knee. The suppuration ex- 
tending through the leg had been accompanied by the most severe con- 
stitutional derangement. A probe being passed through the openings 



SUPPURATION IN BONE. 53 

hi the soft parts to the tibia, this was found to be denuded of perioste- 
um through its entire length and circumference. The knee and ancle- 
joints were acutely painful. The boy was emaciated, his countenance 
flushed, his pulse very frequent and feeble, his nights sleepless from 
pain. I felt certain that the primary disease had been inflammation of 
the medullary membrane of the tibia, from the severity and rapid pro- 
gress of the symptoms, and especially from the extension of the in- 
flammation through the articular ends of the bone to the joints of the 
knee and ancle. A week after the admission of the boy into the hos- 
pital, it became evident that amputation of the limb afforded the only 
chance of preserving his life. In consequence of his exhausted state 
I did not venture to remove him from the water-bed upon which he lay, 
but drew him to the edge of it, and there removed the limb. His re- 
covery was complete. 

On examining the lhnb, I found purulent fluid in the knee and ancle- 
joints, with the almost complete destruction of their articular cartila- 
ges. The shaft of the tibia, in its whole extent, was denuded of peri- 
osteum, but the membrane was entire except in the spots where incis- 
ions had been made through it for the discharge of matter. The inner 
surface of the periosteum was extremely vascular, so soft and velvet- 
like as to resemble acutely-inflamed conjunctiva. Through the medul- 
lary tube and cancellous tissue of the bone there were deposits of thick 
purulent fluid. The walls of the bone were no where perforated : 
hence the certainty that the purulent fluid found within it was the pro- 
duct of inflammation hi the medullary membrane. The epiphyses at 
both ends of the tibia were loosened by suppuration between them and 
the shaft. A commencing line of separation at each end of the bone, 
near the epiphyses, indicated that the shaft had perished ; this, indeed, 
was to be expected as the consequence of inflammation hi the medulla- 
ry membrane and in the periosteum, with the entire separation of the 
latter from the bone*. 

The following cases will further illustrate the history of inflammation 
in the medullary membrane : — 

Acute inflammation in the ITead of the Tibia, probably commencing 
in the medullary membrane. The following history well illustrates the 
severity of the local effects and constitutional derangement occasionally 
produced by these acute affections of bone, whether originating in the 
periosteum or medullary membrane ; for, in this instance, as in others 

* Museum of St. Bartholomew's Hospital. First series, No. 195. Plate 7, fig. 1. 

5* 



54 SUPPURATION IN BONE. 

which I have seen, it was not readily determined in which of these 
structures the inflammation commenced. 

A youth, aged sixteen, having a strumous constitution, complained 
of slight pain in the knee-joint, which had not arisen from local injury 
or other apparent cause. At the same time, a little thickening and 
tenderness were discovered in the soft parts upon the inside of the head 
of the tibia. These symptoms continued several days but little influ- 
enced by treatment, when the most acute inflammation suddenly arose 
within the joint and in the soft parts around the head of the tibia. The 
.•accompanying pain was most severe ; active local depletion did but lit- 
He to mitigate it. There was also high inflammatory fever with deliri- 
um, which continued without intermission above a week, and was not 
calmed by the largest doses of opium. All these symptoms were re- 
lieved, however, by the bursting of a large abscess a little below the 
knee. Extensive denudation of the tibia ensued, and was followed by 
exfoliation of a large portion of its shaft with permanent anchylosis of 
the knee-joint. 

Acute inflammation in the medullary membrane of the Tibia*. " A 
man, aged twenty, who had suffered from suppuration in the cervical 
and axillary absorbent glands, was attacked by erysipelas in the left 
leg, accompanied by severe pain and inflammatory fever. Ulceration 
ensued in the soft parts, exposing the whole inner side of the tibia. 
Diarrhoea came on, and, for the, preservation of life, it became neces- 
sary to amputate the limb above the knee, on the forty-third day from 
the commencement of the disease. On examining the limb, all the 
soft parts were found infiltrated with bloody serum. The periosteum 
of the tibia, denser and more vascular than it is naturally, adhered but 
loosely to the bone, and plates of osseous matter were deposited in its 
tissue. There were several ulcerated channels extending through the 
walls of the bone to the medullary tube. Several portions of the bone 
"between these channels had perished. The medullary membrane, in 
;some situations, was of a deep red colour, resembling the conjunctiva 
'of the eye in chemosis, and in others it was black, with a gangrenous 
odour." 

Suppuration in the bones of the Tarsus and Metatarsus. A man, 
aged 70, was admitted into St.Bartholomew's Hospital with disease in 
his foot, which commenced twelve months previously, without apparent 

* Journal Hebdomadaire des progresses sciences, Novembre, 1834, related by M. 
Dubrueil, Professor in the Faculty of Medicine, Montpellier. 



SUPPURATION IN BONE. 55 

cause. A fistulous passage in the upper part of the foot extended to 
the tarsal bones, and, at the bottom of it, much rough and loose bone 
could be felt. The disease spread gradually through the entire tarsus 
and metatarsus, accompanied by sloughing and suppuration in the sur- 
rounding soft parts. Amputation of the limb could not be proposed, 
on account of the feebleness and advanced age of the patient. He 
died two months after his admission. On examining the foot, I found 
that the articular cartilages had disappeared from the whole of the 
joints of the tarsus and metatarsus ; and that the cells of the bones 
were filled with purulent fluid. Every tarsal and metatarsal bone was 
the seat of suppuration through its cancellous tissue*. 

Inflammation in the medullary tissue of the Femur and of the Ti- 
bia. A boy, 14 years of age, without apparent cause, was suddenly 
attacked by pain deep in the thigh, and, at the same time, by more se- 
vere pain deep in the leg. The whole limb quickly became enormously 
swollen, from the hip to the ancle. Extensive suppuration ensued in 
the soft parts around the tibia. Free incisions were made for the dis- 
charge of the matter ; but the boy became hectic and sank rapidly. 
On examining the limb, I found a large quantity of matter around the 
tibia, and that its periosteum had been in great part destroyed. In 
those situations where portions of the periosteum remained, new osseous 
substance was deposited upon the bone. Around these osseous depo- 
sits, the walls of the bone had extensively ulcerated, and some of its 
outer lamellae had perished. Within its medullary tube lymph had 
been deposited. In the thigh similar changes had taken place, but in 
a less active form. No matter had formed around the femur ; its peri- 
osteum was entire, but there were osseous deposits on the bone, and 
lymph was deposited within its medullary tube. 

The history of this case indicated, that inflammation occurred simul- 
( taneously in the medullary tissue of the femur and of the tibia, but 
most severely within the tibia, and here, consequently, the most de- 
structive effects ensued on the surface of the bone and in the soft 
parts around inf. 

.The diagnosis of abscess in bone requires particular notice. 
The symptoms which belong to the neuralgic affection of bone, and 
to simple inflammation of its tissue, have, in many instances, so closely 

* Museum of St. Bartholomew's Hospital, First series, No. 217, Plate 6, fig. 7. 
t Sections of the tibia and femur are preserved in the museum of St. Bartholomew 1 ? 
Hospital, First series, Nos. 51, 52. 



56 SUPPUEATION IN BONE. 

resembled those of circumscribed abscess as to render the diagnosis be- 
tween these disorders a matter of difficulty ; and yet it is a diagnosis 
of much importance, for the right determination of the cases wherein 
the operation of perforating the bone should be undertaken with the 
expectation of finding matter within it. 

The neuralgic affection of bone has the following special features, — 
the nervous or hysteric character of the constitutional symptoms — the 
pain, although severe, yet not confined to a limited district of the bone, 
and not aggravated by motion of the part, and occasionally attacking 
the corresponding bone of the opposite limb ; further, the pain not 
yielding to depletory or sedative remedies. On the other hand, the 
symptoms accompanying the circumscribed abscess in bone are not in 
general such as bespeak the nervous or hysteric character of the dis- 
ease ; yet upon this distinction Ave must not too confidently rest. The 
abscess in bone, especially when occurring in females, has given rise to 
well-marked nervous local and constitutional symptoms ; and if, in com- 
bination with such nervous symptoms, there should be, as I have known 
to occur, thickening and tenderness of the coverings of the bone, it 
will be really difficult to determine whether the source of pain is exclu- 
sively a neuralgic affection of the bone, or whether there is not, at the 
same time, matter confined within it. 

The diagnosis between circumscribed abscess and inflammation of 
bone, unaccompanied by suppration, is not always well marked. In 
some instances, simple inflammation, and in others syphilitic inflamma- 
tion, of bone have so closely resembled the circumscribed abscess as to 
be mistaken for it. These inflammatory affections, it is true, mostly 
arise in the shafts of bones, whilst the circumscribed abscess rarely oc- 
curs elsewhere than within their articular ends ; yet, under the follow- 
ing circumstances, difficulty in the diagnosis has been experienced. 
Part of the shaft of a long bone has gradually enlarged from inflamma- 
tion in its tissue ; then, upon the occurrence of a fresh paroxysm of in- 
flammation, increased swelling of the bone has ensued with such sever- 
ity of pain as to have led to the supposition that there must be matter 
confined within it. But the result has proved the source of suffering 
to be no other than the tension and stretching of the inflamed perioste- 
um over the swollen bone. The following is the history of such a case, 
and I have known others similar to it. 

A gentleman, about 25 years of age when I first saw him, had been 
for five years suffering from an enlargement of the shaft of the tibia, 
presumed from its history to be syphilitic. The swelling was well de- 



SUPPURATION IN BONE. 57 

fined, hard throughout, and of the size of the closed hand. Through 
the whole progress of the disease, the swelling had scarcely ever been 
free from pain ; but there had been paroxysms of severe pain in it,- and 
each paroxysm was followed by increase of its size. Mercury, iodide 
of potassium, and sarsaparilla had been largely and long administered : 
local remedies of every kind had been perseveringly employed, but, 
from the whole of the treatment, only the remission of pain for a time 
had been obtained. At length, on the occasion of a paroxysm of suf- 
fering with increased swelling of the bone, an incision of considerable 
length was made through the coverings of the swelling, freely exposing 
the hard osseous substance of which it consisted. This measure was 
followed by immediate and complete relief from pain, and there was no 
recurrence of it. A different view of the nature of this case might 
have led to the perforation of the tibia, in the expectation of finding 
matter within it. 

TREATMENT OP SUPPURATION IN BONE. 

Here the principal consideration relates to the measure of perforating 
the bone, for the discharge of the matter which is confined within it. 

The merit of ascertaining the circumstances which indicate the con- 
finement of a small quantity of matter in a circumscribed cavity within 
bone, belongs to Sir Benjamin Brodie, who has thereby effected a great 
improvement in this department of surgery. In several instances, he 
has been enabled to make a successful application of this knowledge, 
by perforating the bone, and thus obtaining an outlet for the matter 
with immediate and complete relief, after which the cavity in the bone 
has been filled, probably with fibro-cellular tissue, and the wound over 
it has healed soundly. Limbs have thus been saved which, without 
such well-applied surgical interference, would probably have been sub- 
mitted to amputation. The following is an abstract of the evidence 
which Sir B. Brodie has furnished on this subject.* In a case where 
the lower part of the tibia had become enlarged, and had been the seat 
of constant pain for twelve years, when the limb was amputated, a 
cavity, about the size of a walnut, containing discoloured pus, was 
found in the tibia, about half an inch above the ancle-joint, with 
hardening of the surrounding cancellous texture. In another case, 
the disease had existed more than 10 years in the head of the tibia, 

* Observations on Diseases of the Joints, and Lectures on Pathology and Surgery. 



58 SUPPURATION IN BONE. 

which had enlarged, and the pain was most severe. Sir B. Brodie 
states, " that his attention was directed to a spot about two inches 
below the knee, to which the pain was especially referred. This part 
of the tibia was exposed by a crucial incision of the integuments. 
The periosteum was scarcely thicker than natural, and the bone be- 
neath was hard and compact. A trephine, of a middle size, was ap- 
plied, and a circle of bone was removed, extending into the cancellous 
texture, but no abscess was discovered. I then, by means of a chisel, 
removed several small portions of bone at the bottom of the cavity 
made by the trephine. As I was proceeding in this part of the ope- 
ration, the patient suddenly experienced a sensation which he after- 
wards described as being similar to that which is produced by touching 
the cavity of a carious tooth, but much more severe, and immediately 
some dark-coloured pus was seen to issue slowly from the part to which 
the chisel had been last applied." From this instant the pain ceased, 
and did not return. The wound healed soundly, and the patient con- 
tinued well. In a third case, the disease was situated in the lower 
end of the tibia, and had existed eighteen years. As the symptoms 
indicated the probability of there being an abscess in the bone, Sir B. 
Brodie applied a trephine to it, and on removing portions of the can- 
cellous texture with a narrow chisel, about a drachm of pus suddenly 
escaped from a cavity in the bone. There was no recurrence of pain. 
The cavity became filled with granulations, the wound cicatrized, and 
the patient remained perfectly well. To the foregoing, other cases 
have been subsequently added, in which the operation of perforating 
a bone, for the discharge of matter from within it, had a successful 
issue ; and it is to be observed that, with one exception, all these cases 
occurred in either the head or the lower end of the tibia.* 

With respect to the mode of perforating a bone for the discharge of 
matter from within it, but few observations are required. Sufficient 
exposure of the bone for the application of a small trephine, or other 
perforating instrument, to its surface, is the first stage of the operation. 
The selection of the right spot for the perforation is a point requiring 
the most careful attention. The rule should be, that the chief seat of 
pain is the spot to be selected ; but even when this has been duly ob- 
served, the perforation of the bone has been made a few lines in one or 
other direction away from the abscess. Therefore, when the perfora- 
tion is continued as deeply as can be done without the risk of pene- 

* Lectures on Pathology and Surgery, by Sir B. Brodie, 18 16. 



SUPPURATION IN THE BONE. 59 

trating the opposite walls of the bone, if no matter should appear, it 
•will be right to pierce the cancellous texture with a small perforator 
around the passage made by the trephine. At the same time, it must 
be recollected, that the smallest quantity of purulent fluid confined 
within a bone has been the source of very severe suffering ; and that 
when mixed with the blood, which in general freely escapes from the 
inflamed cancellous texture around the abscess, the purulent fluid might 
not be distinctly recognised. The character of the fluid escaping from 
the bone should, therefore, be closely scrutinized. 

Perforation of the outer table of the skull has been performed for 
the discharge of matter from the diploe. Mr. Abernethy states, that 
he had seen several cases of suppuration in the diploe, where, the tre- 
phine having been early applied, the external table came away within 
the circle of the instrument ; "the matter was discharged from the 
medullary part of the bone, and the internal table remained sound and 
entire, covering the dura mater. Granulations soon arose, and the 
patients got well with the exfoliation only of a portion of the outer 
table."* I cannot, from my own observation, refer to similar instances 
of the successful use of the trephine. 

In many cases which I have witnessed, injury to the skull in some, 
and disease of it in others, was followed by such symptoms as suppura- 
tion hi the diploe might be expected to produce, but they were not 
sufficiently well marked to warrant the application of the trephine, and 
the cause of the symptoms was afterwards ascertained to be, not sup- 
puration in the diploe, but inflammation of the membranes of the brain. 
The application of the trephine, therefore, in such cases, could but 
have added to the existing mischief. In other cases where suppura- 
tion in the diploe had occurred, the outer table of the skull was perfo- 
rated, but it was of no avail, as the accompanying inflammation in the 
membranes of the brain proved fatal. I have also known instances 
where suppuration in the diploe being suspected, the trephine was ap- 
plied and matter discovered ; not, however, in the diplo, but betY/een 
the bone and the dura mater ; and in one case which I examined, the 
matter appeared to have formed upon the dura mater, and to have . 
passed through a fissure in the inner table of the skull to the diploe, 
which it pervaded to a considerable extent. 

When, in cases of suppuration in the diploe of the skull, the accom- 
panying inflammation in the membranes of the brain does not destroy 

* Surgical Observations, Vol. ii. 



60 SUPPURATION IN BONE. 

life, necrosis of the outer table at the seat of the abscess will probably 
ensue, forming a complication of disease that is usually of slow prog- 
ress, and uncertain result. Constant pain in the head, with paroxysms 
of severe suffering usually occur in these cases ; and frequently each 
paroxysm is followed by extension of the disease to a fresh portion of 
the skull, indicated by inflammation in a fresh portion of the scalp, and 
by the elevation of it into a soft puffy swelling. I have known cases 
of this kind to endure for years, not admitting of other aid from sur- 
gery than a soothing treatment, with the occasional removal of loose 
pieces of the dead bone. But such a case is often suddenly brought 
to a fatal termination, by an attack of inflammation in the membranes 
or substance of the brain, of which I have seen several instances. Ac- 
tive surgical interference in these cases cannot be safely employed. 
No measures of an irritating character can be resorted to, for the ob- 
ject of expediting the exfoliation of the dead bone, from the risk of ex- 
citing inflammation in the brain ; and, for the same reason, no attempt 
should be made to remove the dead bone until its looseness indicates 
that its separation from the living bone is completed. It is true, that 
the presence of a necrosed portion of the skull is accompanied by the 
hazard of fatal inflammation in the brain, even when no other than the 
most soothing treatment has been employed. In the museum of St. 
Bartholomew's Hospital there are two examples of abscess in the ante- 
rior lobe of the brain, from individuals in whom an almost sudden ter- 
mination of life occurred whilst portions of the frontal bone were slow- 
ly exfoliating. Nevertheless,, in such cases, we are bound to wait until 
the exfoliation of the dead bone is completed. 



CHAPTER V 



ON CARIES, THE CONDITION OF BONE ENSUING FROM 
SUPPURATION IN ITS CANCELLOUS TEXTURE. 

I pass from the history of suppuration in bone to the consideration 
of peculiar changes in its cancellous texture, which it is intended 
to comprise in the term caries. 

The term caries is often employed to designate ulceration of bone,, 
whether arising from simple inflammation or from malignant disease. It 
is also used to designate a peculiar organic change in bone, which con- 
sists in a crumbling or mouldering of its substance : in the museum of St. 
Bartholomew's Hospital* there is a tibia, a portion of the shaft of which 
is converted into a soft and crumbling yellowish substance ; and I have 
been accustomed to consider this as an example of the condition of 
bone from which some of the ancient writers probably derived their de- 
scription of caries. But I purpose here to express by the term caries 
the changes which, under certain circumstances, are consequent on 
chronic suppuration in the cancellous texture of bone. 

Caries is distinguished into the simple, scrofulous, syphilitic, and pha- 
gedenic varieties. To these distinctions there may be no objection, as 
suppuration in the cancellous texture of bone, and the consequent chan- 
ges in it, comprised in the term caries, do occur in the progress of these 
several diseases. And in this view of the nature of caries, its ordina- 
ry causes readily suggest themselves : it ensues from comminuted frac- 
tures of the cancellous texture, or from such injuries as the crushing 
of this texture by a bullet ; it also ensues from the influence of the 
scrofulous diathesis, and from the action of the syphilitic poison : and 
there are instances of caries not referable to any distinct cause. 

Caries exhibits in its progress the following phenomena. Inflamma- 
tion extending from the bone to its investing soft parts, these become 

* First series, No. 78, Plate 4, fig. 4. 

6 



62 ON CARIES. 

swollen, thickened, and tender; and abscesses are formed in them 
which contract into fistulous passages leading to the diseased bone. 
The periosteum covering the diseased bone becomes thickened, very 
vascular, and readily separable from it. The bone itself is at first 
very vascular, then its cells become filled with a reddish-brown fluid, 
apparently a mixture of blood and pus, and occasionally combined with 
oily particles. Absorption of the bone, but chiefly of its animal part, 
ensues ; that which remains is porous and fragile, and of a grey, brown 
or black colour, probably from decomposition of the matter within its 
cells ; to which cause, likewise, the foetid odour of the matter discharg- 
ed through the fistulous passages may be ascribed. The diseased bone 
may gradually disappear, either by ulceration, or by its discharge in 
fragments through the fistulous passages in the surrounding soft parts. 
Ulceration, in some instances, commences within the bone, hollowing it 
out, and reducing it to a thin shell ; in others, ulceration commences in 
the outer surface of the bone, and extends progressively inwards. 
Whilst these changes are in progress, granulations, very loose and 
spongy, and bleeding on the slightest touch, often arise from the diseas- 
ed bone, filling the cavities in its interior, and protruding through the 
fistulous passages in the soft parts covering it. 

The phenomena just described occur most- frequently and most dis- 
tinctly in the caries of bones composed wholly of cancellous texture ; 
but they are also observed in long and in flat bones ; and among the 
former, most frequently in the tibia. In bones that are deeply situat- 
ed, caries is often accompanied by very little evidence of inflammation, 
either in the bone or in its investing soft parts. Thus the scrofulous 
caries of the spine often advances to the destruction of the bodies of 
many vertebrae, without tenderness in the bones or in the soft parts in- 
vesting them. 

Upon the diagnosis of caries from circumscribed abscess in bone, and 
from internal necrosis, the following observations have occurred. 

Circumscribed abscess is rarely followed by the formation of a fistu- 
lous channel in the walls of the bone and adjacent soft parts, affording 
outlet to the matter. But in caries, and in internal necrosis, such a 
channel is almost invariably formed in the walls of the bone and their 
investing soft parts ; through which channel, in caries, matter is dis- 
charged from the diseased bone ; and in necrosis, from the inflamed 
cancellous texture around the dead bone. 

Between caries and internal necrosis there are no distinctive external 
characters : both being followed by the formation of a fistulous channel 



ON CARIES. 63 

in the walls of the bone, and both being accompanied by pain in the 
bone, continuing so long as the source of irritation, which is the carious 
or dead bone, exists. Practically, the diagnosis between caries . and 
internal necrosis is of no moment, as the object of treatment in each is 
the same — the removal of the diseased, or dead bone. Moreover, ca- 
ries and necrosis often exist together in adjacent portions of bone, as 
in the instances where suppuration ensues in the cancellous texture ad- 
jacent to dead bone. The portion of bone which has been long cari- 
ous often perishes, and thus the caries becomes changed into necrosis. 
Such are the circumstances which lessen the value of a diagnosis of 
these affections by their external characters. 

TREATMENT OF CARIES. 

Inflammation precedes suppuration and the consequent disorganiza- 
tion of the cancellous texture of bone which constitute caries. But 
the inflammatory action is mostly of a languid character, not, therefore, 
likely to be arrested by depletory remedies : such remedies are, how- 
ever, serviceable by diminishing the inflammation of the soft parts 
around the diseased bone. 

There are natural processes of cure of carious bone. It may sepa- 
rate into minute fragments, and be thus discharged through the fistu- 
lous passages in the adjacent soft parts ; or when separated from the 
healthy bone, the carious bone may remain loose in a suppurating cavi- 
ty, the walls of which are formed by the surrounding bone, or in part 
by the soft tissues adjacent to it. The loose and carious bone enclosed 
within this cavity becomes an irritant to the surrounding parts, exciting 
pain in them, and maintaining a purulent discharge from them. Such 
are the circumstances under which the question often arises — whether 
measures should be taken to effect the removal of the carious bone. 
But the propriety of an operation in these cases is often doubtful, from 
the following circumstances : — There may be difficulty in ascertaining 
the extent of the caries, as the thickening and consolidation of the sur- 
rounding soft parts often extend much beyond the disease in the bone. 
Again, when caries attacks a bone so large as the os calcis or astraga- 
lus, it may be impossible to determine whether part or the whole of the 
bone is affected. The number and situation of the fistulous passages 
in the surrounding soft parts are not decisive evidence on this point. 
One portion of the carious bone loose in its suppurating cavity, may 
be readily discovered by a probe ; whilst another portion of it, not yet 
separated from the sound bone, may have no fistulous passage leading 



64 ON CARIES. 

to it. When caries attacks a bone which, like the astragalus, is wedg- 
ed between the adjacent bones, and surrounded by articular surfaces, 
it is difficult to determine whether the disease is confined to it, or has 
extended to the adjacent joints and bones. So with respect to the cu- 
neiform bones ; when one of these is the seat of disease, it is often dif- 
ficult to decide whether or not the disease has extended to the adjacent 
tarsal and metatarsal bones. 

Similar considerations apply to another combination of disease, often 
not distinguishable from caries, and of not infrequent occurrence, espe- 
cially in the tarsus, namely, circumscribed abscess and internal necro- 
sis. Such a case presents the same thickening of the surrounding soft 
parts and fistulous passages in them as are observed in caries. I had 
in St. Bartholomew's Hospital, at the same time, three cases of disease 
in the bones of the tarsus : one, abscess and necrosis in the os calcis, 
consequent on the perforation of it by a nail ; another, abscess in the 
head of the astragalus ; and the third, an instance of suppuration 
through the cancellous texture of the middle cuneiform bone. And in 
all these cases the question was carefully considered, whether it would 
be expedient to undertake the removal of the diseased bone ; but the 
uncertainty of the nature and extent of the disease was in each case 
decided to be a sufficient ground for preferring amputation just above 
the ancle-joint. 

Most of the operations for the removal of carious bone occur in the 
hand or foot ; and in the performance of them, we are to be guided by 
the principles observed in the treatment of the mutilations of these 
parts by violence. We know the importance, in such cases, of pre- 
serving a single finger with the smallest portion of the palm of the 
hand for its support. So in operating on these parts when diseased, it 
is desirable to remove no more than the bone which is actually unsound. 
In the foot, the largest and most important of its bones, the astragalus, 
and the os calcis, have been severally taken away with less injury to 
its powers and actions than might be expected. Even after the loss of 
the entire os calcis, the tread and the walk will still be firm and secure, 
though wanting, of course, the lightness and spring derived from the 
action of the muscles of the calf upon the heel. 

Incisions through the soft parts over carious bone are of use in afford- 
ing free outlet to the matter, and thus checking its diffusion through 
the bone. Local applications to carious bone should be of a soothing 
nature. Stimulant remedies applied to it will not have the effect either 
of arresting the caries or of restoring soundness to the bone ; and in 



ON CARIES. 65 

proportion to the degree of excitement such remedies occasion, will be 
the risk of their producing fresh attacks of inflammation in the bone, 
and thus extending the caries. 

There are cases of caries not suited for any operative proceeding for 
the removal of the diseased bone, either because the patient is too far 
advanced in life, or on account of some peculiarity of constitution pro- 
hibiting it. Under such circumstances, the mischiefs incidental to the 
continuance of the disease are, attacks of severe pain in the bone and 
inflammation in the periosteum, whenever obstruction occurs to the free 
escape of the matter from the carious bone : this is likely to happen in 
instances of caries in the cancellous texture of the tibia, where the 
walls of the bone have become thickened, and the fistulous passage in 
them leading to the carious bone is so narrow as not to afford free out- 
let to the matter. For such a condition of disease a counter-irritant 
will be of no avail ; reliance must be had on depletory and sedative 
remedies, local and constitutional, for the relief of the pain in the 
bone ; especially on the use of iodide of potassium as the means of ar- 
resting the inflammation in the periosteum covering the diseased bone. 
I attended an elderly gentleman who had suffered more than twelve 
years from caries in the upper part of the shaft of the tibia ; and who, 
through this long period, had numerous attacks of severe pain in the 
diseased part of the bone, and of inflammation in the surrounding pe- 
riosteum ; these attacks recurring whenever the matter ceased to flow 
with its usual freedom through the narrow fistulous channel in the walls 
of the tibia. Abscesses, often of large extent, had again and again 
formed in the parts adjacent to the diseased bone ; but of late years, 
by directly resorting to the use of iodide of potassium, he generally 
succeeded hi arresting the inflammation of the periosteum at its com-' 
mencement, thereby saving himself the suffering and destruction of 
parts incidental to extensive suppurations. 

But in order that a carious bone may endure without extension of 
the disease, and without mischief to the adjacent parts, it is essential 
that these should be maintained in the strictest quietude. For this ob- 
ject, if the caries is situated in the tibia, an almost entire disuse of the 
limb is necessary. In the case just mentioned, of caries in the shaft 
of the tibia, which had endured many years, the limb was, on a partic- 
ular occasion, used more freely than usual ; this was directly followed 
by increased pain in the bone, and by acute inflammation within it, 
occasioning necrosis of its cancellous texture, extending through the 

head of the tibia to its upper articular surface. Consequently, the 

6* 



66 ON CARIES. 

matter formed around the dead bone escaped into the knee-joint, caus- 
ing suppuration within it. A free incision into the joint gave vent to 
a large quantity of matter ; but beneath this accumulation of disease 
the patient, of an advanced age, sunk. Mr. Lawrence attended this 
gentleman through the latter stage of his disease, and he communicat- 
ed to me the foregoing particulars respecting the mode of its termina- 
tion. He obtained the examination of the limb, and found that a large 
portion of the cancellous texture of the head of the tibia had perished, 
and was separated from the walls of the bone, and that the ulcerated 
cavity around the dead bone communicated above with the knee-joint, 
ithe cartilages of which were completely destroyed. 



CHAPTER- VI 



ULCERATION OF BONE. 

" There is, I believe," Mr. Hunter observes, " no difference between 
the ulceration of soft parts and of bone*." Although it is difficult to 
obtain clear evidence of a process in bone agreeing with the definition 
of ulceration by Hunter, namely, " absorption attended with suppura- 
tionf ," yet, looking to the organic constitution of bone, we find, even 
in its compact tissue, the conditions essential to ulceration. Bone is 
certainly liable to a destructive process analogous to the ulceration of 
soft parts, and the varieties of ulcer in bone are as distinctly marked 
as they are in other tissues. 

The ulceration of bone which is the effect of simple inflammation in 
its tissue usually begins at a single point, and spreads equally in width 
and depthj. When, however, the ulceration is consequent on inflam- 
mation of the periosteum, it spreads widely over the surface of the 
bone, but does not, in general, deeply penetrate its substance. 

Syphilitic ulceration of bone usually begins at many points, distinct, 
yet close together, giving to the surface of the bone a worm-eaten 
appearance§. 

Malignant ulceration of bone is generally irregular in its outline and 
surface ; and it extends, in a manner to form excavations in the bone 
of unequal length, width, and depth, with sharp overhanging mar- 
gins || . 

The surface of ulcerated bone is rough and porous, except in the 
instances where its texture had been previously hardened by inflamma- 

* Lectures on the Principles of Surgery, 
t Treatise on the Blood, Inflammation, &c, 
t Plate 4, fig. 3. 
§ Plate 4, fig. 1. 
1] Plate 4, fig. 2. 



68 ULCERATION OP BONE. 

tion. Around the ulcer of bone, from simple inflammation, its texture 
becomes expanded and hardened*, with changes analogous to thick- 
ening of the tissues around an ulcer in soft parts. Also, around the 
ulcer of bone from simple inflammation, osseous deposits occur in the 
periosteum, in the form of tubercles and spines, which, when of con- 
siderable extent, unite into rock-like masses of osseous substance. 
The syphilitic, scrofulous, or other specific ulcer of bone, is not accom- 
panied by these changes, either in the surrounding periosteum or bonef. 

Ulceration of bone occurs as a distinct and primary disease ; it is 
thus recognized in the vertebrae, also in the articular surfaces of bones, 
more especially in the head of the femur ; and it here constitutes a 
peculiar disease of the hip-joint, of which the following are the princi- 
pal features. 

It occurs, I believe, only in adults; rarely, if ever, in females. 
Often it is traceable to local injury ; in many instances, to rheumatism ; 
but in some cases there has been no apparent cause of the disease. 
Its chief symptoms are, a sense of weakness and uneasiness, scarcely 
amounting to pain, in the hip-joint. Thus the disease has endured for 
months, even for years, advancing very slowly, and with so little dis- 
tress to the joint, that, throughout, the strength and movements of the 
limb have been but little impaired. At length, shortening and ever- 
sion of the limb ensue from the destruction of part' of the head of the 
femur. 

Many times, in examining the adult hip-joint, I have found that the 
ligamentum teres and articular cartilage, with part of the osseous sub- 
stance of the head of the femur, had disappeared ; and that, in some 
instances, both hip-joints were similarly altered. These, it is probable, 
were examples of this ulcerative disease attacking the head of the fe- 
mur : and it is proved, by the observation of cases, that a hip-joint 
which has suffered these changes to the extent here stated may, upon 
the cessation of the disease, still be free and strong in its movements. 
But in some cases, so large a part of the head of the femur has been 
removed, that the small portion of it which is left will not remain in 

* Plate 4, fig. 3. 

t Weidman, in his treatise, De necrosi ossium, has given the following good summa- 
ry of the characters of ulceration of bone from simple inflammation : Locus ulcerosus, 
scaber, excavatus, in quo contextus ossis spongiosus apparet patulis ubique ossium 
cellulis. Textus osseus novus circum partem ulceratam enatus, et primigeno super- 
additur, varie tuberculatus, orificiis plurimis refertus, magnitudine diversis, qua? in 
canaliculos recipiendis vasis inservientes ducunt. [Explicatio tabulae primae.] 



ULCERATION OF BONE 69 

the acetabulum: it passes out of the cavity, and at the same time the 
capsule of the joint yields, and is elongated ; these changes being ac- 
companied by considerable shortening of the limb and lameness, which 
must be permanent. In the following case the features of this disease 
were well marked. 

Ulceration of the head of the Femur. _ A cavalry officer, aged 
sixty-three years, who had seen much active service, requested me to 
examine his limb, on account of the very gradual shortening of it; 
to relieve himself from the inconvenience of which he had added half 
an inch to the thickness of the heel of his boot. I found by careful 
and repeated measurement, that the limb was shortened to the extent 
of an inch. He stated that he had not suffered from rheumatism or 
gout ; that he had met with no accident ; but that, about seven years 
ago, without apparent cause, he began to feel uneasiness in the hip- 
joint ; which had continued, with variations, to the present time. The 
shortening of the limb had been in progress about six months ; and it 
appeared to be still increasing. In the morning he was unable to 
move the limb from the stiffness of the hip-joint ; but, by continued ef- 
forts through the day, he became gradually enabled to walk with the 
help of a stick. Every variety of treatment had been fully and per- 
Severingly tried : the impression on the mind of the patient was, that 
the disease in his hip-joint had been wholly uninfluenced by remedies.* 

Ulceration of the articular surfaces of bones in an active form oc- 
curs in the advanced stage of the inflammatory diseases of joints. 
Here the destruction of the bones is accompanied by severe pain ; and 
it will advance, unretarded by remedies, so long as there is any move- 
ment of the ulcerated surfaces upon each other. Even the movement 
of an ulcerated bone upon soft parts is very painful and disturbing to 
the system. Such appears to be the source of the suffering endured in 
instances of disease in the hip-joint, followed by displacement of the 
ulcerated head of the femur from the acetabulum; for, in such cases, 
it is proved by experience, that immediate and complete relief from 
pain and constitutional disturbance follow the removal of the ulcerated 
bonef. 

* On this affection of the hip-joint, observations are recorded by Mr. Gulliver, which 
have the merit of originality, as the facts comprised in them had not before been dis- 
tinctly noticed. Edinburgh Medical and Surgical Journal, Nos. 128, 129, Vol. xlvi. 

t Case of Excision of the Upper end of the Femur in an example of Morbus Coxa- 
rius, by W. Eergusson, Professor of Surgery in King's College, Medico- Chirurgical 
Transactions, Vol. xxviii. 



70 ULCERATION OF BONE. 

The reparation of ulcerated bone is effected in the following ways. 

When an articular surface of bone is the seat of ulceration, upon 
the subsidence of the diseased action, the Haversian canals in the ex- 
posed bone may become filled with earthy matter, giving it such a 
smoothness, polish, and hardness as to fit it for the utmost freedom of 
motion. Such a restorative process is met with in joints of all sizes. 

Reproduction of the cancellous substance removed by ulceration 
from the articular portions of bones, does, under favourable circum- 
stances, take place ; but it is accompanied by the growing together or 
consolidation of their opposite surfaces. From these surfaces, gra- 
nulations are thrown forth which ossify. But the production of this 
osseous anchylosis in a large joint is a very slow process, requiring not 
less than two years for its completion ; it is never effected but in early 
life, and when there is full vigour of the vital powers. Immobility 
of the parts is essential to its production ; for, without this, abundant 
granulations may arise from the ulcerated bones, but the ossification of 
them will not ensue. 

Reproduction of the compact substance of bone removed by ulcera- 
tion does not, I believe, ever occur. There have been instances of 
ulceration extending through a large portion of the shaft of the tibia 
and in its entire thickness ; yet, upon the healing of the ulcerated 
surface, the leg still retained its shape, and was sufficiently strong to 
sustain the weight of the body. But in examining such limbs, I have 
found that [the vacant space in the tibia was filled by dense fibro-cel- 
lular tissue ; and that the strength of the limb was derived from in- 
creased thickness of the fibula, and ossification of the inter-osseous lig- 
ament uniting it to the tibia. 

TREATMENT OF ULCERATION OF BONE. 

On this subject but little can be stated. In the treatment of ulce- 
rated bone, the obvious indications are to prevent the extension of the 
disease, and to promote the reparative processes which belong to it. 

The best local remedies generally applicable to an exposed surface 
of ulcerated bone are those of a soothing nature ; but in some cases 
astringents and mild stimulants are serviceable for the object of pro- 
moting the growth of healthy granulations from the bone. Strongly 
stimulating applications to ulcerated bone are objectionable, as they 
are likely to excite fresh attacks of inflammation in the bone ; and thus 



ULCERATION OF BONE. 71 

they may be the means of changing the character of the disease, by 
giving rise to caries or necrosis in the ulcerated bone. 

It is not to be doubted that a powerful counter-irritant, as the moxa 
or caustic issue, applied to the integuments over a joint the bones of 
which are ulcerated, can arrest the ulcerative process. It may be 
considered difficult to obtain evidence of this ; but it is certain, that in 
ulcerative disease of the bones of the spine, as also in joints, a power- 
ful counter-irritant will get rid of the severe pain which characterizes 
the ulceration of bone in its active form. 

PHAGEDENIC ULCERATION OF BONE. 

There is a form of widely-spreading and, as I believe, incurable ul- 
cer in bone, so'well defined in respect to its mode of origin, characters, 
and progress as to deserve especial notice. 

The tibia is most frequently the seat of this disease, probably be- 
cause it is most exposed to injuries by violence, to which the disease 
can in general be traced. The instances which I have seen of it oc- 
curred in men who had passed the middle period of life, and were of 
intemperate habits. The local injury was followed by successive ab- 
scesses and ulcerations in the soft parts, spreading to the periosteum ; 
and thence the ulceration extended through the bone. Hard wart-like 
granulations arose from the ulcerated surfaces of the soft parts and of 
the bone ; but these granulations had no disposition to cicatrize, and 
they discharged very profusely a thin foetid fluid. In this state I have 
known the disease to continue many years without the slightest effort 
of reparation. It is, however, but a local malady, not contaminating 
the absorbent glands, nor affecting the general health. Therefore, in 
these cases, objection need not be urged to the removal of the limb, in 
the apprehension that malignant disease mil arise elsewhere. The fol- 
lowing are examples of this disease. 

Phagedenic Ulcer in the Tibia. A man, aged fifty-three, was ad- 
mitted into St. Bartholomew's Hospital, with a large foul ulcer in the 
front of the leg, penetrating the tibia. Thirty years previously, a 
heavy piece of timber fell upon his leg, winch was- followed by abscess 
and ulceration of the soft parts. After some time the diseased parts 
became apparently sound, and continued so for twenty years, when the 
same part of the leg was again severely injured. Abscess again form- 
ed, followed by ulceration, which extended through the soft parts to 
the tibia, and then gradually through the bone, destroying a portion of 



72 ULCERATION OF BONE. 

its shaft. Thus a large hollow was formed in the front of the leg, 
from which a profuse foetid watery discharge constantly issued, and the 
margins of this hollow were formed by very vascular, large, hard, wart- 
like granulations. When every means had been ineffectually tried to 
obtain a reparative process, the limb was amputated. On examining 
it, I found the principal arteries ossified ; and that the ulceration, hav- 
ing extended completely through the tibia, had advanced some way 
into the fibula. The ulcerated surface of the bone presented small cir- 
cular hollows, of unequal depth, with sharp overhanging borders*. 

Phagedenic Ulcer in the Tibia. In the year 1805, at the battle 
of Trafalgar, a sailor received a blow on the front of his leg. Ulcera- 
tion of the soft parts ensued:. The ulcer healed, but there remained a 
constant aching in the bone. Several years afterwards^ ulceration re- 
curred in the same parts, and it then extended into the tibia. In the 
year 1818, he was admitted into St. . Bartholomew's Hospital, with a 
wide and deep ulcerated hollow in the front of his leg. The surface of 
this hollow was formed by large and hard granulations, from which a 
profuse thin and foetid discharge constantly issued. The limb was am- 
putated, and, on examining it, I found that four inches of the tibia, in 
nearly its whole thickness, had been removed by ulceration, and that 
the remaining portion of the shaft of the bone was much thickened and 
indurated. 

Phagedenic Ulcer in the Tibia. A man, seventy years of age, was 
admitted into St. Bartholomew's Hospital, under the care of Mr. Earle. 
He stated, that ten years previously he began to suffer severe pains in 
his limbs, which were considered rheumatic, and that soon afterwards, 
the bones of his legs, thighs, and arms began to enlarge ; that two 
years previously he received a blow on the front of the left leg, which 
was followed by abscess and ulceration in the soft parts, extending 
through the periosteum and deeply into the substance of the bone. 
From these diseased processes, the limb had been the source of such 
constant suffering that he solicited its removal. On examining the 
limb, I found the shaft of the tibia enormously enlarged, and indurated 
throughout, with a deep chasm in its lower and front part, occasioned 
by the ulceration of the thickened bone. Above and below this 
chasm, the medullary tube was closed for some way by osseous deposit ; 
but beyond this, the tube was free, and the medulla within it healthy. 
The inter-osseous ligament was ossified throughout, and the fibula was 
much increased in thickness. 

* Museum of St. Bartholomew's Hospital, First series, Nos. 29, 30, Plate 4, fig. 2. 



ULCERATION OF EONE. 73 

Seven weeks after the amputation, the man died suddenly, and, on 
examining his body> an ulcer was found in the stomach, penetrating its 
coats, through which its contents had escaped. The tibia of the oppo- 
site limb, both thigh bones, and all the long bones of the upper limbs 
were greatly enlarged and indurated. 

The peculiar ulceration of bone described in the foregoing cases, is 
analogous to certain examples of ulceration in the skin and subjacent 
soft tissues, spreading widely and deeply, and presenting such peculiar- 
ities of character, that it is often regarded as carcinomatous. 



CHAPTER VII. 



NECROSIS. 



Necrosis is the term applied to the death of bone during the life 
of the rest of the body. Bone, retaining an apparently healthy tex- 
ture, may simply lose its vitality, or it may have previously undergone 
change of structure from disease. In the former case, the bone pre- 
sents no alteration, except what is owing to the stoppage of the circula- 
tion of blood through its vessels ; but in the latter, the condition of the 
bone varies with the nature of its previous disease. Necrosis of the 
shaft of a long bone, in the ordinary mode of its occurrence, is an ex- 
ample of the simple death of bone without change in its structure ; 
but when necrosis has been preceded by chronic inflammation, the dead 
bone will be hardened ; or, after other diseased changes, it may be soft 
and fragile. 

Dead bone usually presents a yellowish white colour, consequent on 
the blood being withdrawn from its vessels : but it often becomes of a 
brown. or black colour. This change has been attributed . to the de- 
composition, either of blood or purulent fluid, in its tissue ; but the 
brown or black colour is often seen in dead bone so situated that puru- 
lent fluid would not readily penetrate it, as, for example, in the most 
convex part of the frontal bone. The colour of dead bone appears to 
be influenced by its exposure to the atmosphere ; thus it is often brown 
or black only to the extent that it is uncovered. The colour of dead 
bone changes in the following manner : first, dark points appear in it ; 
then these increase in number and coalesce, rendering the whole sur- 
face brown or black ; but the change of colour does not extend below 
the surface of the bone, except in the instances of its texture being 
very porous. 

Necrosis occurs less frequently in the cancellous than in the compact 



NECROSIS. 75 

tissue of bone ; the former, by its greater vascularity and vital endow- 
ments, resisting the influence of causes which give rise to necrosis of 
the compact tissue. Hence, gangrene of the cheek (cancrum oris, 
noma) extending from the soft parts to the bones, frequently occasions 
necrosis of the lower jaw, and but rarely of the upper. I have, how- 
ever, seen an instance of gangrene of -the cheek followed by necrosis 
and exfoliation of the entire superior maxillary bone. And it is owing 
to the resisting power in the cancellous texture of bone, that necrosis 
in the shaft of a bone rarely extends to its articular ends. There are, 
however, in the museum of St. Bartholomew's Hospital, instances of 
necrosis involving the articular ends of the tibia. 

With respect to the liability of different bones to necrosis, it may be 
observed, that necrosis occurs more frequently in the shaft of the tibia 
than elsewhere, apparently because its front part, from the thinness of 
its coverings, is especially exposed to such noxious influences as are 
likely to occasion the death of the bone. Next to the tibia is the fe- 
mur in the frequency of its necrosis, and why it should be so is not ev- 
ident. After the femur, the other principal bones may be thus arrang- 
ed, in respect to their liability to necrosis : the humerus, flat cranial 
bones, lower jaw, last -phalanx of a finger, clavicle, ulna, radius, fibula, 
scapula, upper jaw, pelvic bones, sternum, ribs. 

Necrosis is of frequent occurrence in the cancellous texture of the 
head of the tibia. There appears, indeed, to be something in the 
structure and function of the head of the tibia especially disposing it 
to the invasions of disease ; for here, not only necrosis, but also ab- 
scess, is frequent ; and here, also, the malignant affections of bone are 
frequently developed. 

Causes of Necrosis. The recognized causes of necrosis are — cold, 
injury by violence, rheumatism, scrofula, syphilis, fever. Some of 
these causes act directly on the periosteum ; others, on the medullary 
tissue ; and others, on the bone itself. A boy was occupied many 
hours in drawing a truck through deep and melting snow. On the next 
day he suffered severe pain in his leg, and in a few days afterwards, 
suppuration ensued through the soft parts of the leg, and it became evi- 
dent that the tibia had perished. Here it is probable, that the perios- 
teum, medullary tissue, and bone, were all alike attacked by inflamma- 
tion, and that the death of the bone was the consequence. The sever- 
est form of paronychia, which is followed by necrosis of the last bone 
of the finger, probably commences, as Dr. Crampton has suggested, in 



76 NECROSIS. 

inflammation of the periosteum*; and there are instances of necrosis, 
preceded by inflammation of the periosteum, clearly denoted by the 
history to be rheumatic. During the progress of fever, necrosis of the 
shaft of a long bone has occurred without any evidence of previous in- 
flammation, either in the periosteum or medullary tissue. And here it 
might be suggested, that the inflammation and death of the bone are 
analogous phenomena to the local congestions and inflammations occur- 
ring, under similar circumstances, in other organs. In a young fe- 
male, necrosis of the entire shaft of the tibia occurred during an attack 
of fever, from which she died in about a month from its commencement. 
I found the tibia throughout its osseous substance of a deep red colour, 
whilst the medullary tissue was unaltered. But that the bone had per- 
ished was evident, by the entire separation of the periosteum from it, 
and by the lines of separation commencing between the shaft and artic- 
ular ends. Here, therefore, it appeared that inflammation in the tissue 
of the bone had preceded its necrosis. 

There are instances of necrosis, affecting a portion or the entire shaft 
of a bone, not traceable to any distinct cause. An individual in good 
health may be suddenly attacked by severe pain in the thigh, leg, or 
arm ; and this, in a few days, may be followed by suppuration deep in 
the limb, the consequence of the death of the bone. A large portion 
of the lower jaw, in young persons, occasionally perishes without any 
previous derangement of health, local injury, or other apparent cause. 
But in some cases, an aching in the bone has preceded the death of it. 
Such examples of necrosis usually occur in early life, between the 
fourth and the twentieth years, but rarely later. In the same order of 
cases are the instances of necrosis attacking two bones simultaneously 
in the same limb, or in distant parts of the body. 

The detachment and removal of periosteum will, it is true, deprive 
the subjacent surface of bone of part of its nutrient vessels ; yet there 
may be no necrosis, even of the outer lamellae of the bone. When, 
however, the periosteum is detached with so much violence as to injure 
the circulation in the vessels of the. bone, then, it is probable, that the 
surface of the bone will perish. 

Necrosis of the upper or lower jaw is, in most cases, but not invaria- 
bly, the effect of some local cause acting on the adjacent soft parts, 
and hence on the periosteum and bone. I had, in St. Bartholomew's 
Hospital, a man, about thirty years of age, in whom, without apparent 

* Dublin Hospital Reports, Vol. i. 



NECROSIS. 77 

cause, necrosis occurred in the entire front and ascending portions of 
both superior maxillary bones. His statement was, that about twelve 
months previously, he began to suffer pain in his upper jaw ; soon after 
which, the teeth fell out of their sockets, and matter was discharged 
into the mouth. When the dead bone was sufficiently loosened, I drew 
away the entire front of each maxillary bone with its alveolar process : 
after which, the surrounding parts healed soundly, but with the per- 
manent hollow in the face resulting from the loss of so large a portion 
of its bony fabric. And this consequence of necrosis of the superior 
maxillary bone may always be expected ; since, under whatever cir- 
cumstances the necrosis has occurred, it is not, as I believe, ever fol- 
lowed by the slightest reproduction of the lost bone. 

Necrosis in a portion of the lower jaw, especially of its alveolar 
process, is occasionally preceded by symptoms of scurvy ; namely, 
swelling and sponginess of the gums, with bleeding from them, and 
much derangement of the general health. But the more frequent 
cause of necrosis in the lower jaw is excessive salivation, when the in- 
flammation in the mucous membrane of the mouth extends through the 
subjacent tissues to the periosteum of the jaw. I have seen an in- 
stance of necrosis in nearly the whole body of the lower jaw, in a case 
of fever, in which only a few grains of calomel had been administered. 
Yet it was followed by excessive salivation and severe inflammation in 
the gums and cheeks*. 

Another cause of necrosis in the jaws, both upper and lower, has of 
late years come into operation, in the manufacture of lucifer-matches. 
Whilst the matches are being dried, a large quantity of phosphorous 
acid vapour is given off from them, with which the air of the drying- 
rooms becomes charged. Many of the persons employed in these 
rooms, and, consequently, exposed to the noxious vapour for several 
hours in the day, have been attacked with necrosis of large portions 
of the upper or lower jaw; and, in some instances, of both jaws. 
A notice of this peculiar form of necrosis has been published by Dr. 
Heyfelderf. In the first case which he saw, he removed a portion of 
the lower jaw, and the patient, a female, returned well to her occupa- 
tion : but a few months afterwards she came again to the hospital, with 
necrosis of the other half of the lower jaw, and also of the upper 

* Museum of St. Bartholomew's Hospital. First series, No. 102. 

t Medicinische Zeitung. Berlin, November, 1845. There is also a Memoir on Ne- 
crosis of the Jaw Bones in consequence of the action of Phosphorus, by F. W. Lo- 
rindser, Chief Surgeon of the district infirmary of Wieden, in Vienna. 

7* 



78 NECROSIS, 

jaw, and she died in a hectic state, after undergoing the disarticulation 
of the second half of the lower jaw. The other cases which occurred 
to Dr. Heyfelder, were all in women occupied in the phosphorus-match 
manufactories at Nurnberg ; and in most of them one half of the jaw 
became affected. Dr. Heyfelder states, that the disease in the jaw 
appeared not to be simple necrosis; the outer surface of the portions 
of bone which he extracted, being covered with a thick layer of grey 
pumicestone-like, newly-formed, osseous substance. He also refers to 
some lower jaws in the possession of Dr. Dietz, of Nurnberg, which 
.are completely covered with a thick layer of grey, newly-formed, 
'osseous substance. In all but one of these bones, also, necrosis had 
vtaken place. 

Similar affections of the jaws have occurred among the lucifer-match 
manufacturers of this country. In the London Hospital there have 
been several of these cases, from the lucifer-match manufactories in the 
neighbourhood. Through the kindness of Mr. Luke, I had the oppor- 
tunity of seeing one of the patients : he was a young and very sickly- 
looking man, with a large swelling of the soft parts on the right side 
•of the face, and fistulous holes just below the lower jaw, through which 
the probe passed upwards to dead bone ; but it did not appear that the 
formation of any new bone was in progress. This man had been em- 
ployed in cutting the lucifer-matches previous to their arrangement in 
boxes ; during which proceeding, he stated, that frequently a large 
number of the matches ignited, and that, in this way, he had been ex- 
posed to the noxious vapours arising from them. We further learned 
.from this patient, that several persons had discontinued the occupation 
•on account of ill health, without suffering disease in their jaws. 

Some cases of disease in the lower jaw, in lucifer-match manufac- 
turers, have been in St. Bartholomew's Hospital, and from these pa- 
ttients I obtained a history of the disease, similar to that which had 
T)een recorded by the German physicians, who were the first to ob- 
serve it. 

It seems well ascertained that the disease is the result of long ex- 
posure to the fumes of phosphorous acid, giving rise to inflammation 
of the periosteum of the jaw, in conjunction with extreme depravation 
of the general health. It has been suspected that the disease was 
owing to the use of arsenic in the manufacture of lucifer-matches ; but 
to this notion it has been properly objected that the smelters of arsenic 
are liable to no such malady ; and it is certain that the disease occurs 
in lucifer-match manufactories" where no arsenic is employed. 



NECROSIS. 79 

With loss of appetite, sallow countenance, and feeble circulation, 
the first indication of the disease is usually tooth-ache, followed by the 
dropping out of the teeth, more especially of the grinders, and then by 
the death of a portion of the jaw, with its attendant evils of foetid dis- 
charge into the mouth, abscess and fistulous passages in the adjacent 
( soft parts. There can be no doubt of the disease being the result of 
exposure to the fumes of phosphorus ; it may be a question, whether 
the fumes act as a local excitant upon the periosteum and bone of the 
jaw, or whether the disease in the jaw occurs secondarily, as a conse- 
quence of the circulating fluids being poisoned by the inhalation of the 
phosphorus. Against the opinion that the phosphoric vapour acts 
merely as a local excitant, the objection has been urged, that it pro- 
duces no effect on the periosteum of the bones of the nasal passages 
through which the vapour is directly inhaled. 

Whichever may be the mode of production of the disease, its effects 
upon the jaw are certain in destroying a portion of it, and under such 
circumstances that no reproduction of the bone will ensue. For here, 
there is a total want of the essential conditions for the reproduction of 
bone, namely, inflammation in healthy structures with health in the 
general system. The grey pumicestone-like osseous substance de- 
posited in these cases from the inflamed periosteum of the jaw, is to be 
regarded as a peculiar morbid product from a diseased tissue. 

Many years ago, Dr. Roupell placed in the museum of St. Bar- 
tholomew's Hospital* several bones from cows obtained from Swansea, 
in the neighbourhood of which there are copper-works, where, in melt- 
ing the copper ore, arsenical fumes are disengaged to such an extent 
as to destroy all animal and vegetable fife within their influence. The 
animals, soon after their exposure to these fumes, become ill and dis- 
abled, from disease in their bones, which, on examination, are found 
enlarged, and covered by deposits of unhealthy osseous substance. 
Here, therefore, it would appear that, in animals, the arsenic, contami- 
nating the circulating fluids, had, through these, excited inflammation 
of the periosteum and bones, of a somewhat similar character to the 
disease which occurs in the jaws of persons occupied in the manufac- 
ture of lucifer-matches. 

There are numerous instances of necrosis attacking small portions 
of bone, some of which seem to require especial notice. 

* First series, Sub-series A. No. 156. 



80 NECROSIS. 

One of the most frequent of these is necrosis of the tuber ischii, or 
of the trochanter major, with the destruction of their soft coverings, in 
feeble systems, from inability to sustain the pressure to which the parts 
are subjected. 

In scrofulous children, necrosis occurs in portions of bones having a 
cancellous texture ; but, in these instances, the death of the bone is 
usually preceded by suppuration through its cells. 

Syphilis produces its effects mostly upon the compact osseous tex- 
ture, and in portions of bones which have thin soft coverings, as the flat 
cranial bones, the front surface of the tibia, and the posterior border of 
the ulna, near the olecranon. One of the modes of action of the 
syphilitic poison is to produce the immediate and complete death of the 
surface of bone it attacks. A circumscribed puffy swelling then arises 
in the investing soft parts, and, in the centre of this swelling, an ulce- 
rated hole speedily forms, leading to the dead bone. 

Rheumatic inflammation of periosteum is another cause of necrosis 
in small portions of bone. This occurs most frequently in the perios- 
teum of the trochanter major, and adjacent parts of the neck and shaft 
of the femur ; and it here constitutes a disease which is, in some cases, 
very tedious and difficult to manage, from the impossibility of getting 
at the dead bone without the risk of injury to the hip-joint, and often 
formidable, in consequence of the hip-joint having become implicated 
in the inflammatory processes adjacent to the dead bone. In the two 
following cases, the features of this disease were well marked. 

Necrosis of the Trochanter Major, from rheumatic inflammation. 
A youth, about sixteen years of age, who had been much exposed to a 
cold and wet atmosphere, was admitted into St. Bartholomew's Hospi- 
tal, suffering from acute inflammation in his hip-joint, which had been 
preceded by pains in other joints. Mercurial ointment was plentifully 
applied to the circumference of the inflamed joint ; calomel and opium, 
with antimony, were also administered, and these remedies were con- 
tinued to the extent of producing salivation, when the inflammation in 
the joint began to subside, and it continued to do so without further 
treatment. He left the hospital with the perfect use of the joint. 
About three months afterwards, an abscess formed directly over the 
trochanter major ; it burst, and a piece of bone, the size of a horse- 
bean, was discharged from it, after which the abscess closed and healed 
soundly. The exfoliated bone appeared to have been part of the 
trochanter. 



NECROSIS. 81 

Necrosis of the Trochanter Major and Base of the Neck of the 
Femur, from rheumatic inflammation. In a female, twenty-seven 
years of age, the disease, commencing with symptoms of rheumatism, 
had been seven years in progress, and it had, for almost the whole of 
this time, incapacitated her from active occupation, the hip-joint 
having become fixed, either by the adhesion of its articular surfaces, or 
by thickening of the tissues around it. Three fistulous passages had 
formed at the upper and outer part of the thigh, which, when exam- 
ined by a probe, were found to converge to the front of the neck of the 
femur, but no loose or bare bone could be detected, and, as it was 
thought, in consequence of the probe not following the tortuous and 
winding tracts of the fistulous passages to their termination. Minute 
fragments of bone had been extracted through these passages ; and as 
the purulent discharge from them was still free, it seemed certain that 
more dead bone yet remained ; but since its situation could not be as- 
certained, no operation could with propriety be undertaken for its re- 
moval. No other resource appeared available than to leave the disease 
to the natural processes which it was hoped might yet be adequate to 
the removal of the dead bone. 

Since, in many of the instances of necrosis attacking small portions 
of bone, it is not possible to make out satisfactorily the history of the 
disease in respect to the cause of the death of the bone, it is necessary 
to dwell on the common feature of all these cases, namely, the ex- 
istence of one or more fistulous passages in the soft parts, often cir- 
cuitous in their course, and the orifices of which in the integuments 
are often at a great distance from the piece of dead bone to which they 
lead. 

A fistulous passage in the soft parts adjacent to dead bone, whether 
this be superficial or deep, is an almost unvarying occurrence. In su- 
perficial necrosis, abscess forms in the adjacent soft parts, and the mat- 
ter tracks its way to the integuments through which it is discharged, 
the abscess then contracting to the fistulous passage which leads to the 
dead bone. And in deep necrosis, implicating only the inner lamellae 
of a bone, a fistulous passage is formed, first in the adjacent walls of 
the bone, and then in the soft parts covering it. Only a single excep- 
tion to this has occurred within my own observation, which was in an 
instance of necrosis affecting portions of the inner lamellae of the fe- 
mur, and of the tibia in the same individual. Here the perished inner 
lamellae have completely separated from the living bone ; yet there is 



82 NECROSIS. 

no fistulous passage in the walls either of the femur or of the tibia*. 
Under these circumstances, it is not to be expected that abscess and 
fistulous passages would form in the soft parts adjacent to the bone 
which is the seat of necrosis. 

Symptoms of Necrosis. Necrosis of the outer lamellae of a bone is 
not, in its early stage, readily distinguishable from other inflammatory 
affections of either periosteum or bone. 'The phenomena ordinarily at- 
tendant on its progress are — separation of the periosteum from the dead 
bone ; inflammation of the periosteum, followed by suppuration beneath 
it, and by ulceration of it with the investing soft parts, affording outlet 
to the matter, and terminating in a fistulous passage leading to the 
dead bone. 

Necrosis of the inner lamellae of a bone has its characteristic signs. 
Ordinarily, its first symptom is pain deep in the bone ; but, in some in- 
stances, febrile disorder is the first . symptom, continuing many days 
and even weeks, and then subsiding with the commencement of pain in 
the bone. The death of the inner lamellae of a bone is followed by 
suppuration in the adjacent cancellous texture, also by the formation of 
a narrow fistulous passage in its walls, through which the matter es^ 
capes from the interior. Whilst these changes are going on within the 
bone, inflammation arises in the soft parts covering it, accompanied by 
a soft circumscribed swelling of the integuments, from which, when 
punctured or allowed to burst, matter will be discharged. Through 
the abscess in the soft parts, the orifice of the fistulous passage in the 
walls of the bone may be detected ; but it may be so small as not to be 
found, and then the real nature of the disease will not, for a time at 
least, be known. Mr. Hey states that, in one case, he was led to sus^ 
pect the existence of an aperture in the walls of the bone, from ob- 
serving that more matter issued from the outward wound than the sur- 
face of it ought to have furnishedf , and I have had opportunities of 
confirming the truth of this observation. 

An exception to the foregoing statement of the phenomena conse- 
quent on necrosis of the inner lamellae of a bone, has been just refer- 
red to, in an instance where the death and separation of the inner la- 
mellae of the femur and of the tibia, in the same individual, did not 
give rise to a fistulous passage in the walls of either bone. 

Necrosis of the shaft of a bone in its whole thickness, whether limit- 

* Museum of St. Bartholomew's Hospital, First series, Sub-series A. Nos. 118, 119. 
•f Practical Observations in Surgery, on Caries of the Tibia. 



NECROSIS. 83 

ed to a portion of its length, or extending through the whole of it, pre- 
sents the following features. 

Febrile disorder, in some cases, precedes the death of the bone ; 
but, in most instances, a sudden attack of pain deep in the limb is the 
first symptom of it, and this is quickly followed by excessive inflamma- 
tion in the soft parts, with accompanying fever. The first of the 
changes immediately consequent on the death of the bone is, that the 
periosteum no longer retains any hold upon it, and when separated 
from the bone the periosteum becomes acutely inflamed ; the inflamma- 
tion thence extending through the other tissues of the limb to the in- 
teguments, where it presents either a phlegmonous or erysipelatous 
character. In the several structures of the limb, the inflammation will 
terminate either in serous effusion, simply enlarging it ; or in the depo- 
sit of fibrin, consolidating its textures ; or in suppuration beneath the 
periosteum, and in the intermuscular cellular tissue, giving rise to one 
large abscess, or to many small abscesses in different parts of the limb.. 
Incisions are in general required for the discharge of the matter from 
these abscesses ; and then, unless there is any unusual source of irrita- 
tion maintaining the suppuration, the quantity of matter secreted will 
gradually diminish, and some of the passages through which it has 
been discharged will become closed, whilst others, remaining fistulous, 
will lead to the cavity in which the dead bone is enclosed. Whilst 
these changes are in progress, the bulk of the limb will be gradually 
lessened by the absorption of the serum or fibrin diffused through it ; 
but its several tissues will remain so densely consolidated and compact- 
ed together, that if an incision be made into them, they will be found 
to consist of a firm brawn-like substance, in which the original struc- 
ture and arrangement of the parts can scarcely be recognized. 

Necrosis of the shaft of a bone, through the entire circumference 
and thickness of its walls, is usually accompanied by the death of its 
medullary tissue to a corresponding extent. There are, however, in- 
stances of necrosis, the consequence of some strictly local cause, act- 
ing only on the surface of the bone, in which the walls of the bone per- 
ish, whilst the medullary tissue preserves its vitality. Such were the 
circumstances of the following case :— nitric acid was applied to a 
phagedenic ulcer in the leg ; its action extended to the periosteum of 
the tibia, occasioning inflammation of the periosteum over nearly the 
whole extent of the bone. The walls of the bone, in consequence, 
perished ; and the limb was amputated. In the examination of it, not- 



84 NECROSIS. 

withstanding the death of the entire walls of the bone, the medullary 
tissue was found to have preserved its vitality*. 

Necrosis of the shaft of a bone near its articular end is often follow- 
ed by the extension of inflammation to the adjacent joint ; thus, dis- 
ease in the knee-joint has ensued from necrosis, in either the femur or 
the tibia near its articular end ; and I have known instances of disease 
in the hip-joint, the consequence of necrosis in the trochanter major of 
the femur. In another way, destruction of a joint has ensued from 
necrosis in its neighbourhood ; namely, by the abscess, which had form- 
ed in the soft parts around the dead bone, bursting into the joint. 
Destruction of the joint then quickly followed, with the severe consti- 
tutional disorder which always follows the bursting of abscesses into 
large joints. It is true, that disease in a joint, which has been the 
consequence of necrosis in its neighbourhood, is often with difficulty 
distinguishable from the acute affections of joints arising in other ways ; 
yet attention should be alive to the occurrence of such cases. More 
than once I have been present at the examination of an amputated, 
joint, when there was occasion for regret, that before the operation it 
had not been ascertained that a small piece of dead bone lay loose, 
but imprisoned within the living bone, near to the joint, whence it 
might have been easily removed ; because, if this had been done, the 
disease in the joint might have been expected to subside. 

When the bone attacked by necrosis is of small size, or only a small 
portion of it had perished, and in a patient who is not of an irritable 
habit, the inflammation which ensues in the surrounding soft parts is 
usually so mild that it gives rise to the effusion of fibrin or of serum, 
without suppuration, the disease then passing through its several stages 
unaccompanied by any other change than the simple enlargement and 
thickening of the parts adjacent to the dead bone. Under such cir- 
cumstances, difficulty is often experienced in determining the nature of 
the disease, for it may then be doubtful whether the enlargement of the 
limb has been caused by necrosis, or by chronic inflammation of the 
bone, or by thickening of the periosteum, such as occurs in scrofulous 
children, in whom the periosteum of one bone, or of several, often be- 
comes so much thickened as to produce an enlargement of the limb, 
simulating that which is caused by disease in the bone itself. 

Necrosis of a portion of the cancellous texture within the articular 
end of a bone is a very formidable disease, as it is so often followed by 

* Miiseum of St. Bartholomew's Hospital, First series, No. 19, Plate 7, fig. 2. 



NECROSIS. 85 

the destruction of the adjacent joint. The most frequent seat of this 
disease is the head of the tibia, to which the following account of it 
will particularly refer. It mostly occurs between the ages of fifteen 
and twenty years. Often it arises without appreciable cause ; but, in 
some cases, it appears to have been the consequence of a blow upon 
the knee. Here the necrosis, although in. general of small extent, is 
formidable, from its proximity to the knee-joint, which, in all the instan- 
ces that I have seen, at an early or late period, became involved in the 
inflammatory processes set up in the parts adjacent to the dead bone. 
In some cases, the disease has rapidly run its course, by speedily caus- 
ing destructive inflammation of the joint ; whilst in others, its progress 
has been slower, extending through many years of almost constant suf- 
fering, accompanied by gradual disorganization of the joint. 

The dead portion of the cancellous texture within the head of the 1 
tibia is rarely so large as a hazle nut ; its situation varies, being nearer 
to the front or back wall of the bone, or to its upper articular surface ,, 
in one case than in another. The separation of the dead from the liv" 
ing bone usually takes place in an early stage of the disease. The 
piece of dead bone is then loose in a suppurating cavity, lined by a 
thick and very vascular membrane, from which pus is secreted more or 
less abundantly, according to the degree of excitement in the surround- 
ing parts. The dead bone, being an irritant, excites constant pain, 
with successive attacks of inflammation, in the adjacent living bone ; 
also in its periosteum and in the knee-joint. Consequently, the sur- 
rounding cancellous texture becomes hardened, and narrow ulcerated 
passages, which become fistulous, extend in various directions through 
the hardened bone to the front or back wall of the tibia, or towards its 
upper articular surface. If these ulcerated passages extend through 
the wall of the bone to its periosteum, matter will then accumulate be- 
neath the periosteum, or ulceration of the periosteum will ensue, per- 
mitting the extension of the abscess into the surrounding soft parts. 
If one of the ulcerated passages in the bone should extend upwards to 
its articular surface, and then open into the knee-joint, rapidly destruc- 
tive inflammation of it will ensue. During the progress of the disease, 
the periosteum investing the head of the tibia and the cellular tissue 
around it, become thickened and indurated, thus giving to the bone the 
appearance of actual enlargement. In illustration of the foregoing 
history, the following case is related. 

Necrosis of the cancellous texture ivithin the Head of the Tibia. In 
a female, sixteen years of age, without appreciable cause, attacks of 

8 



86 NECROSIS. 

pain occurred in the upper part of the leg. Shortly after their com- 
mencement, an abscess burst in the front of the leg, a little below the 
knee ; the opening became fistulous, and continued so through the next 
sixteen years, constantly discharging matter. A probe passed into this 
opening entered the head of the tibia. Incisions had been many times 
made down to the bone, and several small exfoliated portions of the 
cancellous texture of the head of the tibia had been taken away, with, 
however, but little benefit ; more or less constant aching in the bone 
continued, with occasional paroxysms of severe pain, each of which was 
followed by a more profuse discharge of matter. Latterly, the attacks 
of inflammation had extended to the knee-joint. The increase of pain 
was attended with aggravated constitutional derangement, and the gen- 
eral health became so seriously affected that, at the age of thirty-two, 
when the disease had been sixteen years in progress, the removal of 
the limb was decided to be a necessary measure. On examining the 
amputated limb, I found a dead portion of the cancellous texture, 
about the size of a hazel nut, firmly impacted in the interior of the 
head of the tibia, half an inch below its upper articular surface. The 
dead bone was, therefore, so situated that its removal by operation 
could scarcely have been effected without penetrating the knee-joint. 
The several structures of the joint had undergone the usual changes 
consequent on long-continued inflammation ; the synovial membrane was 
thick and pulpy, with lymph adhering to its free surface. The crucial 
ligaments were softened, and the articular cartilages were in part ab- 
sorbed*. 

Although necrosis of the cancellous texture, within the lower articu- 
lar end of the tibia, is much less frequent than within the head of the 
bone, yet I have known it to occur, and to be followed by the destruc- 
tion of the ancle-joint. 

The history of necrosis through its further stages is now to be 
traced. 

Mode of Separation of Bead from Living Bone. The separation 
of dead from living bone is termed exfoliation ; and the separated piece 
of dead bone is termed sequestrum. The process of exfoliation is anal- 
ogous to that by which any of the softer solids of the body, having 
lost their vitality, become separated from the living structures. The 
separation of a slough from soft parts, and the exfoliation of bone, pre- 

* Museum of St. Bartholomew's Hospital, First series. No. 123, Plate II, fig, 3. 



NECKOSIS. 87 

sent similar phenomena, with the differences only which result from the 
difference in their organization. This fact has been ascertained, as 
well by observation of the process of exfoliation in the human subject 
as by experiment in animals. 

If, in a living animal, a bone is rubbed with caustc, or otherwise in- 
jured to the degree of causing necrosis of its surface, a red line in the 
contiguous living bone will speedily appear, just as increased vasculari- 
ty shows itself in the skin immediately around an eschar. In either 
instance, an increased vascularity of the living tissue, contiguous to 
that which has perished, is the first stage in the process of separation. 
Along the red line in the living bone, a groove between it and the dead 
bone is then formed, which gradually deepens, until the separation of 
the dead bone is complete. Mr. Hunter observed that this groove is 
formed by the absorption of the living bone adjacent to the dead bone, 
and that the earthy matter of the living bone first disappears ; conse- 
quently, that the bone is softened before the groove appears in it*. 
Whilst the dead bone is separating, by the gradual deepening of the 
groove between it and the living bone, the groove becomes filled by 
granulations growing from the exposed surface of the living bone. 
Hence, in the section of a bone, where exfoliation is in progress, a soft 
vascular tissue is found to occupy the line of separation ; and in de- 
taching a piece of dead bone, the subjacent surface of the living bone 
is found to be covered with a soft, velvet-like, layer of very vascular 
granulations ; further, upon the exfoliated surface of dead bone, small 
circular hollows are seen, which exactly fitted to the granulations from 
the living bone. 

The layer of granulations beneath an exfoliating bone sometimes 
causes it to emit a hollow sound when struck with a probe ; this was 
noticed by the old writers, and commented upon by them as diagnostic 
of " the corrupted bone," as they called it. 

The exfoliation of bone and the shedding of the antlers in deer are 
analogous processes. The antler becomes softened at its base previous 
to its separation, just as living bone becomes softened preparatory to 
the formation of the groove between it and the dead bone ; and the 
separation of the antler exposes a very vascular and velvetlike surface, 
like the granulating surface of living bone exposed by the detachment 
of dead bone. 

Mr. Hunter was the first to investigate the exfoliation of bone as a 

* Experiments on the Growth of Bone and on Exfoliation. Hunter's Works, 8vo. 
Vol. iv. p. 315. 



88 NECROSIS. 

vital process. He observes, that " the notion entertained before his 
time was, that the dead bone rotted away ;" but he adds, " the bone 
is only dead, not putrid." The results of Mr. Hunter's experiments 
on animals are shown in a series of preparations preserved in his mu- 
seum, which display the process of exfoliation through all its stages. 
And as the great object, in the mind of Hunter, was the investigation 
of the actions of life in health and in disease, through all the forms of 
animated nature, it was not likely that the appearances observed upon 
the surface of a treo, from which a portion of the bark has been re- 
moved, would fail to attract his attention, from the resemblance they 
exhibit to the process of exfoliation of bone ; accordingly, in his muse- 
um, this subject was commenced by preparations exhibiting the process 
in wood analogous to exfoliation in bone*. These preparations show, 
that the separation of a layer of wood, which has perished after the 
removal of the bark covering it, takes place in the same manner that 
a superficial exfoliation of bones ensues after the detachment of the 
periosteum. 

In modern times, the process of exfoliation has been investigated by 
the microscope, and with the following results : " When a portion of 
dead or dying bone, is about to be separated from the living, the pro- 
cess which occurs," says Mr. Groodsir, " is essentially the same as that 
which has been described [in the account of the separation of a slough 
in soft parts] . The Haversian canals, which immediately bound the 
dead or dying bone, are enlarged contemporaneously with the filling of 
their cavities with a cellular growth. As this proceeds, contiguous ca- 
nals are thrown into one another. At last, the dead or dying bone is 
connected to the living by the cellular mass alone. It is now loose ? 
and has become so in consequence of the cellular layer, which sur- 
rounds it, presenting a free surface, and throwing oif pusf ." This 
statement is of especial interest, as a confirmation of the accuracy of 
Hunter's view of the subject, obtained without the advantages enjoyed 
by the modern microscopic observer. The remarks of Mr. Goodsir, 
that the dead bone, in the latter stage of its exfoliation, is connected 
with the living bone by a cellular mass alone, corresponds with the rep- 
resentation of Hunter, that the process of exfoliation commences with 
the absorption of the earthy matter in the living bone contiguous to the 
dead bone. 

* Catalogue of the Hunterian Museum. 

t Anatomical and Pathological Observations, by John and Harry Goodsir, Edin- 
burgh, 1845. 



NECROSIS. 89 

The foregoing views derive additional interest from an examination 
of the chemical qualities of the pus discharged from the parts adjacent 
to exfoliating bone. About ten years ago, Mr. Thomas Taylor exam- 
ined for me some pus taken from an ulcer around an exfoliating portion 
of the tibia, and he noticed the large quantity of phosphate of lime 
which this pus contained, but bestowed no further attention on the sub- 
ject. More recently, Mr. Bransby Cooper has observed, and accu- 
rately recorded, the characters of the pus obtained from the neigh- 
bourhood of exfoliating bone. His statements on the subject are, 
" that the discharge arising from diseased bone contains a large quan- 
tity of the solid constituents of bone in solution, which, consequently, 
pass off in these fluids ;" that " the discharge from a case of diseased 
bone was found to yield, after incineration, from 72 grains of pus — 

Phosphate of lime . . . ■ . 175 grs. or 2-43 per cent. 
Carbonate of lime and soda 1-5 grs. or 208 per cent." 

Thus, "in the pus from parts around diseased bone, phosphate of 
lime was found in amount nearly 2 1-2 per cent., whilst in pus 
elsewhere obtained, only traces of phosphate of lime were discovered*. " 

Mode of removal of Bead Bone. There are facts which, appa- 
rently, prove that, in some instances, dead bone disappears without any 
sensible exfoliation of it. The following appear to be examples of this 
process : — In a middle-aged man, a severe attack of inflammation oc- 
curred in the walls of the tibia. An abscess formed over the bone, on 
opening which, the bone was found to be denuded of its periosteum. 
The surface of the exposed bone became of a dark brown colour. A 
few days afterwards, I observed a point of florid granulation rising 
from the centre of the discoloured bone ; and, by means of a probe, 
this granulation was ascertained to have arisen through a minute canal 
in the walls of the bone, extending to its medullary cavity. Each day 
there was an addition to this small mass of granulations, and a cor- 
responding enlargement of the canal in the walls of the bone, which, 
in about a week, was sufficiently widened to admit the passage of my 
finger into the medullary cavity. Another man had necrosis of the 
shaft of the ulna. Abscesses burst over the dead bone, which, when 
exposed, became of a dark brown colour to a considerable extent. 
The general health, which had been much deranged, gradually im- 
proved ; and, at the same time, granulations from the surrounding soft 

* Lectures delivered at the Eoyal College of Surgeons, reported in the Medical Ga- 
zette, May, 1845. 



90 NECROSIS. 

parts, gradually extending over the dead bone, completely enclosed it. 
The parts then became soundly healed without any apparent exfolia- 
tion. In a case where a portion of the front of the tibia perished, and 
had become of a black colour, granulations from the surrounding soft 
parts were observed to extend gradually over the dead bone. Whilst 
this was in progress, I raised, upon the edge of a spatula, the free 
border of these granulations, and exposed little hollows in the surface 
of the dead bone, to which the granulations were exactly fitted*. In 
these several instances, the dead bone certainly disappeared, but not 
by any sensible exfoliation ; the question will be respecting the mode 
<of its disappearance. 

In accordance with the doctrines of Hunter, it has been generally 
considered that, in such instances as those just adduced, the dead bone 
disappears by the agency of the absorbent vessels in the granulations 
adjacent to it ; and, in confirmation of this view, the fact has been 
noticed, of the granulations being always in contact with the dead 
bone whilst this is in progress of removal ; and, besides, that the gran- 
ulations are so exactly moulded to the dead bone, as to indicate that 
they are the agents whereby the hollows in its surface are produced. 
Now, however, it being denied, upon grounds which are presently to 
be explained, that dead bone is ever absorbed into the system, we refer, 
with interest, to the account which has been rendered by Miescher, of 
a process of exfoliation, in which the dead bone is detached in parti- 
cles so minute as not to be detected by the unaided sight, and which, 
therefore, has been designated, insensible exfoliationf. It is stated by 
Miescher, that the dead bone gradually disappears by the detachment 
of extremely minute and thin scales from its margin J ; that at the bot- 
tom of dry wounds, where there is exfoliating bone, such scales may 
be detected, but that, from their delicacy, the sharpest sight may not 
:readily recognize them§.„ Such a view of insensible exfoliation cer- 

* The following case, to the same effect as the instances above adduced, is recorded 
Tby Ruysch. A man fell from the horse on which he was riding ; a portion of the scalp, 
;over the frontal bone, was, in consequence, destroyed. The changes which ensued in 
the denuded bone are thus described : '« Hsec ossis denudatio in totum nigricabat, cir- 
culo excepto, qui cuti proximus straminis latitudinem obsidebat. Hoc circulo albo de 
die in diem diminuto, patiens convaluit sine ulla visibili ossis separatione." Euysch, 
-Observat. Anatom. Chirurg., Obs. v. 

f De Innammatione ossium — Pars Pathologica : Prsegressa exfoliatione in particulis, 
s. insensibili, p. 201. 

I Margo tenuissimus lamellae emortuse tanquam corrosus apparebat, atque submissa 
lanceola, facillime in particulas minutas dilabebatur. Loc. cit. 

§ Exfoliationem revera fieri, ita yero exiguas esse particulas secedentes, ut oculorum 
aciem prorsus fugiunt. Loc. cit. 



NECROSIS. 91 

tainly accords Tvith the ascertained fact of there being a larger quan- 
tity of the earthly salts of bone in pus obtained from the neighbour- 
hood of exfoliating bone. But it affords no explanation of the circular 
hollows to which the granulations are exactly fitted in the exfoliated 
surface of dead bone : it is, indeed, impossible to regard these hollows 
in the dead bone, as produced otherwise than by the agency of the 
granulations which are in contact with them. 

An exfoliated piece of bone is always of less extent than the space 
in the living bone from which it was withdrawn. Hunter explained 
this by the absorption of the margin of the living bone during the ex- 
foliating process ; and, in the same view, he referred to the fact of the 
margin of an exfoliated bone being always beset with spicula, " whilst 
the surface of the edges of the remaining bone, so far from corres- 
ponding, is quite smooth*." 

I have often, with interest, noticed a distinct pulsatile movement in 
the matter filling the cavity of a bone where exfoliation is going on ; 
and I have supposed this movement to be derived from the arteries of 
the part pulsating against the fluid pus with more than their usual 
force. In relation to this curious occurrence, Mr. Hunter has thus 
expressed himself: " The pulsation of the matter, lying in a hole over 
the part where this process [exfoliation] is going on, I account for, by 
supposing that the impulse from all the subjacent granulations center 
in this hole containing the matter, as the motion of the mercury would 
be invisible in the bulb of the thermometer, but is evident in the thread 
of itf." 

When the exfoliating process is completed, the dead bone is, in some 
instances, gradually extruded from the cavity in which it is lodged ; 
and this appears to be effected by the pressure of the surrounding 
granulations against it. But the extrusion of the exfoliated bone may 
not ensue ; either in consequence of its large size, or from its being 
enclosed within a tube of the newly-formed bone ; and the next ques- 
tion for consideration -will be, whether the exfoliated bone, remaining 
■within its cavity, will undergo any change, — whether the adjacent liv- 
ing parts can act upon it and effect its removal. 

It has been confidently held, that such a process does occur ; but, in 
modern times, experiments and observations have been brought for- 
ward to show, that upon exfoliated bone the living parts can exert no 

*Hunterian Eeminiscences, by James Parkinson, 4to. p. 124. 
t Hunterian Reminiscences, p. 124. 



92 NECROSIS. 

action ; consequently, that it will remain unchanged, irritating, as a 
foreign body would do, the parts in its neighbourhood. It has been 
reported, that Sir William Blizard confined a layer of bone upon an 
ulcer in a man's leg, and that, when removed twenty-four hours after- 
wards, its weight was diminished, and its surface, which had been in 
contact with the granulations, was excavated. But this experiment 
has been often repeated in man and in animals with a different result. 
I have confined a layer of bone upon an issue, but neveu found its 
weight lessened, or its characters in any way changed. I have, also, 
confined pieces of bone in various situations within the bodies of ani- 
mals, but never observed that they had undergone the slightest altera- 
tion. To the same effect are instances of comminuted fractures in 
man, where fragments of bone, which have been for many years en- 
closed within the living parts, are found unaltered, with the sharp 
edges and angles that are seen in recently fractured bones. Further, 
in a memoir on this subject by Mr. Gulliver, a series of well-contrived 
experiments are detailed, the results of which all tend to refute the 
doctrine of the removal of exfoliated bone by the agency of the living 
parts, and, in fact, wholly disprove the absorption of it.* 

It often happens that dead bone, completely separated from the 
living bone, is yet firmly fixed by the close adhesion of the surround- 
ing soft parts to its surface. Hence the difficulty experienced in get- 
ting away pieces of dead bone in cases of necrosis and of compound 
fracture. Such adhesion of the living parts to dead bone may per- 
haps be analogous to the natural connexion of the vascular with the 
extra-vascular parts of an animal body, namely, the hair, nail, cuticle. 
It has, indeed, been ascertained by Mr. Gulliver that, under certain 
circumstances, exfoliated dead bone may become again firmly adherent 
to living bone ; thus, portions of dead bone introduced into the me- 
dullary cavity of the tibia in rabbits, and allowed to remain there for 
several weeks, acquired a firm adhesion to the adjacent living bonef ; 
and specks of osseous substance deposited from the living bone were 
found upon the surface of the dead bone, and firmly adherent to it$. 
Miescher, in his experiments on the process of exfoliation, observed the 

* Experimental Enquiry on Necrosis, Medico- Chirurgical Transactions, Vol. xxi. 

t The adhesion of dead to living bone is, of course, of the same character as the ad- 
hesion of a bullet to living bone. I opened the body of a man who was at the battle 
of Waterloo, and found a bullet projecting from the posterior surface of the sternum, 
but immovably fixed in its cancellous texture, which it had penetrated. 

t Medico- Chirurgical Transactions, Vol. xxi. 



NECROSIS. 93 

granulations from the adjacent living "bone penetrating the medullary 
canals of the dead bone*. In this way the firm adhesion of exfoliated 
bone to the living parts would be readily explained. 

The exfoliation of bone is an uncertain process, in respect to the ra- 
pidity of its progress ; nor can this always be explained by the circum- 
stances of the age or health of the individual : for, in some instances, 
the process advances more actively in old than in young persons — in 
those of feeble health than in others of robust constitution. There are 
also instances of necrosis in which the separation of the dead bone 
never commences ; and other instances in which the process having 
commenced, is, without appreciable cause, arrested in its progress. 
The following is an instance of the latter kind. Amputation of the 
thigh was performed thirty-five years after a fracture of the femur, 
which had been followed by abscesses in the soft parts, and the forma- 
tion of a fistulous passage in the walls of the bone, which was still open 
at the time of the removal of the limb. A section of the femur dis- 
covered a small portion of its inner wall of a dark brown colour, and 
in parfexfoliatedf. Here, therefore, it appeared that a portion of the 
inner wall of the femur having perished, its exfoliation was but in part 
effected : it had retained its connexion with the living bone, and through 
the long period of thirty-five years, had been the source of suffering, 
which, at length, induced the patient to solicit the removal of the limb. 
That dead bone may thus retain its comiexion with living bone for an 
indefinite period, is an important fact, as it bears upon the question 
hereafter to be considered, — under what circumstances operations for 
the removal of dead bone may with propriety be undertaken. 

Reparative Processes consequent on Necrosis. Here we are to con- 
sider the various circumstances connected with the production of new 
bone to supply the place of that which has perished. 

If only part of a bone has perished, its remaining portion and the 
surrounding soft parts become inflamed, and the changes which ensue 
in these parts constitute the first stage in the process of reproduction. 
Through its subsequent stages this process is diversely modified, accord- 
ing to the situation and extent of the dead bone, and by other circum- 
stances hereafter to be stated. 

=*Loc. cit. p. 199. 

t Museum of St. Bartholomew's Hospital, Eirst series, No. 176. For the history of 
this case, and for the possession of the specimen, I am indebted to Mr. Pritchard, of Le- 
amington. 



94 NECROSIS. 

Necrosis in the outer lamellae of a bone, when accompanied by de- 
struction of its coverings, including the periosteum, gives rise to the 
following changes — thickening and consolidation of the inner lamellae 
of the bone, inflammation of the surrounding periosteum, occasioning 
osseous deposit beneath the membrane, and in its tissue ; and in this 
way the dead bone becomes circumscribed by a thick projecting border 
of new osseous substance. In the instances which I have examined, 
the depression in the surface of a bone, consequent on the exfoliation 
of its outer lamellae, was found filled with fibrous tissue. But in the 
experiments of Miescher, it appeared that reproduction of the exfoli- 
ated outer lamellae was effected by ossification of the granulations filling 
the space between the dead and living bone*. 

It was shown by Mr. Hunter, that necrosis of the outer lamellae of 
a bone in animals is, under certain circumstances, followed by phenom- 
ena different from those which have been just described. The experi- 
ments of Hunter were made upon the metacarpal and metatarsal bone s 
of the ass ; and they appear to have consisted in the cauterization of 
the bone, with as little injury as possible to the soft parts covering it. 
Necrosis and exfoliation of the outer lamellae ensued. Osseous sub- 
stance gradually extended from the surrounding living bone over the 
dead bone, which thus became enclosed, except at one part, where it 
remained exposed, and where there was a fistulous passage in the soft 
parts leading to it. In the manuscripts left by Hunter, it is stated to 
have been his opinion, that the new osseous substance enclosing the 
sequestrum was formed by ossification of the granulations arising from 
the surrounding parts. His reflections on this curious process are thus 
expressed — " While nature is busied in getting rid of that part of the 
bone which is dead, she is laying on additional bone on the outside ; 
the intention of which seems to be, that of keeping up the strength of 
the bone, which would, without this addition, be lessened by the loss of 
substance. This opinion is, I think, supported by this circumstance 
seldom occurring in this manner in any of the bones but those of the 
lower extremity, which support the animal. If this is true, it is a cu- 
rious process by which nature endeavours to support the strength of 
these bones during a loss of substance, by throwing on the outside, 

* Miescher observes, with respect to the granulations filling the space between the 
dead and living bone, " quarum id stratum quod ossi proximum est, ossificatur, exteri- 
us vero cum granulationibus quae ex partibus mollibus natse sunt confluit, et ad confin- 
gendam cicitricem cutis confert." Loc. cit. p. 236. 



NECROSIS. 95 

bone in proportion to the loss of substance within*." The preparations 
displaying the results of these experiments are contained in the Hun- 
terian museum ; they show the progressive enclosure of the exfoliating 
bone in the osseous cavity formed around it ; they also show, that the 
granulations arising from the bottom of this cavity gradually extrude 
the dead bone from it ; and that, by the ossification of these granula- 
tions, the cavity becomes obliterated. The peculiar results of Hunter's 
experiments appear to be owing to the circumstance, that, in them, the 
soft coverings of the bone were carefully preserved, especially the pe- 
riosteum, which would take so large a share in the production of the 
new osseous substance enclosing the dead bone. On the other hand, 
in man, necrosis of the outer lamellae of a bone is usually accompanied 
by destruction of the soft parts, and especially of the periosteum cov- 
ering the dead bone. 

If, in animals, the entire periosteum of the shaft of a bone is taken 
away, and lint wrapped around the bone, to prevent the reunion of its 
surrounding parts, the phenomena which ensue are, necrosis and exfo- 
liation of the outer lamellae, in the form of a complete cylinder, and the 
reproduction of the lost bone by ossification of the granulations arising 
from the exposed inner lamellae f . And from this experiment it might 
be concluded that, in the human subject, certain specimens of necro- 
sis, apparently consisting in the death of the entire shaft of the bone, 
and in the production of a new bone, chiefly by the periosteum, were 
actually instances of necrosis affecting only the outer lamellae, and fol- 
lowed by the production of new bone from the exposed surface of the 
inner lamellse. But it is doubtful whether, in the human subject, the 
reproductive power of the tissue of bone is adequate to the formation 
of so great an extent of new bone. In the human subject, the repro- 
duction of the outer lamellae of a bone can probably be but imperfect- 
ly, if at all, effected without the aid of the periosteum. 

When necrosis extends through the walls of a bone to its medullary 
tissue, the reproduction of the lost bone will be effected chiefly by the 
medullary tissue, or by the periosteum, according to circumstances. 
The activity of the reproductive power possessed by medullary tissue, 
was manifested in the following instances. In a man whose arm was 
torn by machinery, above four inches of one side of the ulna were de- 

* Works, 8vo. Vol. i. p. 526. 

t Troja, de nororum ossium regeneratione experimenta, 1775. Meding, Diss, de re- 
gen, ossium, 1823. 



96 NECKOSIS. 

tached by a longitudinal fracture. Granulations, arising from the ex- 
posed medullary tissue, filled the vacancy in the walls of the bone, and 
it appeared to be by the ossification of these granulations, that the re- 
production of the lost bone was effected. In a dog, I removed part of 
the walls of the tibia, exposing its medullary tissue. Granulations 
soon arose from this tissue, filling the vacancy in the walls of the bone, 
and when the animal was killed, these granulations had become partly 
ossified*. 

■If, with necrosis of the walls of a bone, its periosteum as well as the 
medullary tissue is preserved, the production of new bone will chiefly 
ensue from the internal surface of the periosteum. This mode of re- 
production was exemplified in the case already referred to, where in- 
flammation of the periosteum of the tibia followed the application of 
nitric acid to a phagedenic ulcer in the leg, and on examining the am- 
putated limb, it was found that the dead walls of the tibia had exfoliat- 
ed from the cancellous and medullary tissue, and that the production 
of new bone was taking place from the internal surface of the perios- 
teum!. 

When necrosis attacks the inner lamellae of a bone without extend- 
ing to its medullary and cancellous tissue, the reparative process which, 
under favourable circumstances, may ensue, consist in the consolida- 
tion, by osseous deposit, of the medullary tissue, in the thickening and 
induration of the outer lamellae, and in the deposit of osseous substance 
upon the surface of the bone, beneath the periosteum. When the 
separation of the inner lamellae is completed, the dead bone will be con- 
tained in a cavity between the thickened outer lamellae and the consol- 
idated medullary tissue. 

When the entire inner lamellae of a bone have perished, the dead 
bone is separated in the form of a tube, of varying thickness in diffe- 
rent instances. Around the exfoliating inner lamellae the outer lamel- 
lae become consolidated together, and increased in thickness, by new os- 
seous substance deposited on the outside of the bone. Such conse- 
quences frequently ensued in former times, after amputation, from in- 
flammation in the medullary membrane of the remaining portion of the 
bone. In the museum of the Royal College of Surgeons, there are 
many examples of this form of necrosis, most of them in the femur, and 
all exhibiting' a tube of dead bone either withdrawn from the cylinder 
formed by the thickened outer lamellae, or still enclosed within it. But 

* Museum of St. Bartholomew's Hospital, First series, No. 12, Plate 8, fig. 3. 
t Museum of St. Bartholomew's Hospital, First series. No. 19. Plate 7, fig. 2. 



NECROSIS. 97 

these specimens exhibit the results of the surgery of a former age ; 
whilst, in the museum of St. Bartholomew's Hospital, which contains 
only modern specimens of disease, notwithstanding the richness of its 
collection of diseased bones, there is only a single example of necro- 
sis of the entire lamellae of a bone after amputation. This occurred 
in the humerus ; and the amputation was performed on account of 
compound fracture. 

We have in the next place to consider the reparative process, conse- 
quent on necrosis of the entire thickness and circumference of the shaft 
of a bone through a part or the whole of its length. 

There are four distinct sources of reproduction, which may severally 
be concerned in the formation of the new bone : these are — 1, the pe- 
riosteum ; 2. portions of the original bone detached from its surface 
and remaining connected with the periosteum ; 3. the articular ends of 
the original bone ; 4. the soft tissues around the periosteum, or around 
the bone, if the periosteum has been destroyed. 

There are facts which have been generally considered to prove, that 
periosteum possesses the power of producing bone. Among these, the 
results of the following experiments hold a prominent place. In a dog, 
I removed half an inch of the radius, involving its entire thickness, to- 
gether with the periosteum covering it. In another clog, at the same 
time, I removed an exactly similar portion of the radius, care being 
taken in this instance to leave the periosteum entire, by slitting the 
membrane and separating it from the piece of bone that was taken 
away. Ten weeks afterwards both animals were killed. In the in- 
stance where the periosteum had been preserved, the bone was per- 
fectly reproduced ; but in the other, where the portion of the perioste- 
um had been taken away, the vacancy in the bone was filled only by a 
dense fibrous tissue. Other circumstances of interest were observed 
in the result of this experiment. In the instance where reproduction 
of the bone failed, a principle of compensation from another source was 
manifested, for here, the ulna became greatly increased in thickness 
opposite to the vacancy in the radius, and by this means sufficient firm- 
ness was restored to the hmb for the support of the body of the ani- 
mal*. Experiments similar to the foregoing, and with the same re- 
sults, had previously been made by Mr. Syme, of Edinburgh, to whom, 
therefore, the merit of suggesting them belongs! . 

* Museum of St. Bartholomew's Hospital, Third series, No. 86 — 88. 
f On the Power of Periosteum to form New Bone. By James Syme, Esq., " Trans- 
actions of the Eoyal Society of Edinburgh," Vol. xiv.p. 1. 

9 



98 NECROSIS. 

Of the capacity for ossification in periosteum, and in other fibrous 
structures, under various circumstances of disease, there are many evi- 
dences. To one of these I would refer ; namely, an old ulcer situated 
upon the front of the leg, occasioning, by its irritation, abundant osse- 
ous deposits in the surrounding periosteum, and in the adjacent inter- 
osseous ligament, converting it into a thick plate of bone. It has, in- 
deed, been urged, that the irregular ossification of periosteum in this 
and other such instances of disease, is a different phenomenon from the 
exertion of a reproductive power in forming a bone of a certain size 9 
and of the definite figure and structure required for its functions. 
But, both in the human subject and in animals, I have certainly wit- 
nessed instances of production of the new bone, presenting, to the un- 
aided sight, all the appearances of regeneration by the periosteum 
alone. 

Such instances were similar to the following. In a case of necrosis 
of the shaft of the femur, where the opportunity occurred of examin- 
ing the limb in an early stage of the reproductive process, " the bone, 
for the space of about four inches, was found denuded of its perioste- 
um and rough to the touch. The sides of the cavity occupied by the 
bone were partially composed of a sheath of bony granulations, in some 
spots nearly a quarter of an inch thick, firmly adhering to the perios- 
teum, which itself adhered to the mass of muscles, and evidently pro- 
ceeding from it*." In a case of necrosis of the shaft of the tibia, 
where the limb was amputated five weeks from the commencement of 
the disease, " a dense case, or shell, enclosed the dead bone, which 
proved to be the periosteum, greatly thickened with osseous matter de- 
posited in its substance. The new bone did not constitute a continuous 
shell, but was deposited in scales, between which the periosteum inter 
vened, so as to isolate them from each other. The osseous substance 
lay on the inner surface of the periosteum, with merely a fine film of 
the membrane covering it, but with a considerable quantity of soft ge- 
latinous substance, like coagulable lymph, effused over this, so as to 
line the interior of the case. At several parts, of irregular size and 
figure, the periosteum did not exist, and at these parts there was a cor- 
responding deficiency in the new bonef ." 

In similar instances, obtained by experiments on animals, if necrosis 
of the shaft of a bone is produced, the new bone will be formed, and 

* Principles of Military Surgery, by John Hennen, M.D., p. 127. 
t Clinical Eeport, by James Syme,. Esq., Edinburgh Medical and Surgical Journal, 
January, 1836. 



NECKOSIS. 99 

by a process which has been generally considered to furnish satisfacto- 
ry evidence of the regeneration of bone by periosteum. The Italian 
pathologist, Troja, was, I believe, the first to institute this experiment. 
I have many times repeated it in dogs, and have thus had the opportu- 
nity of observing the phenomena of the reproductive process, which 
are here enumerated in the order of their occurrence : — inflammation 
of the periosteum, deposit of purulent fluid between the periosteum 
and the bone, deposit of gelatinous substance upon the inner surface 
of the periosteum, hardening and ossification of this gelatinous sub- 
stance, separation of the dead shaft of the bone from its articular ends, 
and, lastly, the production of osseous substance from the articular ends, 
which becoming united with the new bone formed upon the internal sur- 
face of the periosteum, the osseous cylinder is thereby completed, and 
its continuity with the articular ends of the original bone established. 
Accordingly, in the first stage of the reproductive process, the perios- 
teum is found soft and pulpy, from inflammation of its tissue, and con- 
solidated with the surrounding parts, so as to form with them a vascu- 
lar bed enclosing the dead bone. Upon the inside of this vascular bed, 
the new bone is formed. The new bone is lined by a layer of soft and 
very vascular tissue, which becomes the medullary membrane, with 
which, under favourable circumstances, the new bone is provided*. 
Dr. Macdonald instituted similar experiments ; but, immediately after 
causing necrosis of the shaft of a bone, he mixed madder with the food 
of the animal : and on examining the parts three days afterwards, he 
found the periosteum thickened, with a deposit of gelatinous substance 
upon its inner surface, in which there were osseous particles tinged by 
the colouring matter of the madderf. 

Such are the principal facts upon which the doctrine has rested that 
the regeneration of the shaft of a bone is effected chiefly by the peri- 
osteum. But a different view of this subject is taken by some modern 
pathologists. By them it is denied that periosteum possesses the power 
of forming new bone, except through the means of portions of the old 
bone separated with the periosteum, and serving as nuclei of ossifica- 
tion ; and it is accordingly affirmed, that in all these instances of the 
regeneration of bone, the periosteum, whether detached from the bone 
in an experiment, or in the process of disease, takes away with it par- 

* The preparations displaying the results of these experiments are preserved in 
the museum of St. Bartholomew's Hospital, First series, Diseases of Bone, Plate 8, 
%s. 1, 2, 4. 

t De Necrosi ac Callo, Disp. Med., Edinb. 1799. 



100 ^- NECROSIS. 

tides, or filaments, of the old bone, and that it is from these the regen- 
erated bone derives its origin*. The appearances which certain speci- 
mens of necrosis present are appealed to in confirmation of these views. 
In such specimens, roughness and excavations are visible on the sur- 
face of the old bone, opposite to the portions of newly-formed bone. 
The explanation of these roughnesses and excavations used to be, that 
they are the result of absorption, by the agency of the granulations 
arising from the internal surface of the newly-formed bone. But the 
absorption of dead bone, under any circumstances, being wholly deni- 
ed, it is now suggested that the roughnesses and excavations, on the 
surface of the old bone, are occasioned by the detachment of portions 
of it with the periosteum. It is not to be denied that, in some instan- 
ces of necrosis, the production of the new bone may be from nuclei 
thus separated with the periosteum ; but there are specimens of necro- 
sis of the entire shaft of a bone, in which the production of the new 
bone certainly appears to have been effected by the periosteum, with- 
out the aid of any nuclei of ossification derived from the surface of the 
original bone. One such specimen, at least, is contained in the muse- 
um of St. Bartholomew's Hospital ; it exhibits necrosis of the shaft of 
the tibia, with the formation of the new bone considerably advanc- 
ed around it. On removing the dead bone from the vascular bed in 
which it lay, its outer surface was found to be so perfectly smooth, in a 
great part of its length, that it appeared impossible that any particles 
or filaments could have been detached from it with the periosteum! . 
No other conclusion, in respect to this specimen, appears to be war- 
ranted, than that the new bone was formed by the periosteum of the 
old bone, which now invests the new bone. If, however, it be true, 
that, under whatever circumstances periosteum is detached from bone, 
whether by experiment or by the process of disease, shreds or parti- 
cles of the bone are removed with it, and that they may be so minute 
as not to be recognized by the unaided sight, then, even in such in- 
stances of necrosis as the one just described, it might be urged that 

* The following are some of the authorities here alluded to :— Midler's Elements of 
Physiology. The observations which its able translator, Dr. Baly, has appended to the 
section on the Eeproduction of Bone after Necrosis, Vol. i. p. 470. Dr. Knox's Obser- 
vations and Cases illustrative of the Pathology and Treatment of Necrosis, Edinburgh 
Medical and Surgical Journal, Vol. xviii. Mr. Goodsir's Anatomical and Pathological 
Observations, Edinburgh, 1843. 

t Eor this valuable specimen my acknowledgment is especially due to the liberality of 
Sir James M'Gregor. Museum of St. Bartholomew's Hospital, First series, No. 133, 
Plate 9, fig. 1. 



NECROSIS. 101 

the shreds, or particles, so detached from the original bone, may be the 
nuclei of ossification, and thus constitute the origin of the new bone. 
But it should be observed, that this view of the subject deprives the 
periosteum of none of its importance in the regenerating process ; for 
if the periosteum be destroyed, the particles of bone connected with it 
must lose their vascular supply, and perish. And, accordingly, in all 
cases of necrosis, the same practical importance should be attached to 
the preservation of the periosteum, as if it were proved to be the sole 
and exclusive source of the regenerative power. 

Two other sources of reproduction in necrosis of the shaft of a bone 
are yet to be noticed ; namely, the articular ends of the bone, and the 
surrounding soft parts independently of the periosteum. 

New osseous substance is produced from the articular ends of the 
original bone ; but it does not appear that this is ever more than suffi- 
cient to effect their union with the newly-formed shaft of the bone. 

It has been a question whether, if the periosteum, with its nuclei of 
ossification, be destroyed, the surrounding soft tissues will take on the 
reproductive power. That this may occur in the human subject and in 
animals is apparently proved by the following facts : — In compound 
fractures of the leg, where a portion of the tibia, in its whole circum- 
ference and thickness, with the periosteum covering it, has been taken 
away, yet the vacancy in the bone has become filled with new osseous 
substance, and the reparative processes have been completed without 
shortening of the limb. Here, the new bone was produced probably 
in part from the adjacent ends of the bone ; but principally, from the 
surrounding soft tissues. In a dog, the medullary tissue of the tibia 
was completely destroyed ; and, at the same time, the periosteum was 
separated from the entire shaft of the bone, and wholly taken away. 
Six weeks afterwards the animal was killed ; and on examining the 
limb, a new bone was found to be in progress of formation around the 
dead shaft of the bone. A similar experiment was made by Mr. Rus- 
sell, of Edinburgh, who states, " that in one experiment, the perioste- 
um was scraped off the bone of the leg ; yet, notwithstanding its re- 
moval, a new osseous mass was formed, with all the appearances which 
usually attend the renovation of bone, and in all the perfection of an 
ordinary case of necrosis*." Again, to the same effect, were the expe- 
riments of Dr. Macdonald. He removed portions of periosteum from 
the bones of birds, in which he had previously destroyed the medullary 

* Essay on Necrosis, p. 26. 

9* 



102 NECROSIS. 

tissue, and found that the formation of new bone took place in the situ- 
ations where the periosteum had been removed, though more slowly 
than in other situations where the periosteum remained.*. 

It thus appears to be well established, that, under certain circum- 
stances, the soft tissues surrounding the dead bone, independently of 
the periosteum, may take an active share in the production of the new 
bone. The circumstances favourable to this mode of regeneration are, 
that around the dead bone there should be a thick stratum of soft 
parts ; and that the inflammation in them, consequent on the death of 
the bone, should have been so mild as to terminate in the effusion of 
serum, or fibrin, rather than in suppuration. By attention to these 
circumstances, we are enabled to explain the partial regeneration of 
the bone which ensues in certain instances of necrosis ; the new bone 
being formed only in those situations where the periosteum of the orig- 
inal bone, and the surrounding soft structures, are uninjured ; whilst, 
in other situations, where, by the violence of the inflammatory processes, 
these structures are destroyed, the reproduction fails. Thus, in necro- 
sis of the tibia, the new bone is frequently formed only to the extent 
of the posterior half of the shaft ; whilst, upon its anterior half, the in- 
flammatory processes having destroyed the periosteum with the thin 
covering of soft parts on this side of the bone, no reproduction here 
ensues ; and, consequently, the new bone, comprising only half the 
cylinder, forms a sort of trough, in which the old and dead bone is 
lodged. Certain instances of the imperfect reproduction of bones, re- 
moved by operation, admit of similar explanation. Thus, in the case 
where Mr. Travers removed the clavicle with its periosteum, on account 
of a tumour originating in it, the newly-formed bone is thus describ- 
ed : — " The production of bone, of a cylindrical figure, from the trun- 
cated extremity of the clavicle, extends at least two inches, and termi- 
nates beneath the centre of the cicatrix, in a firm ligamentous band ad- 
herent to the skinf ." Here, therefore, the new bone was produced 
.only from the portion of the clavicle which had been left in the opera- 
tion ; and, accordingly, in this case, it was seen to what extent the re- 
parative process would ensue unaided by the periosteum, and deriving 
but little aid from the surrounding soft parts. The clavicle being cov- 
ered only by skin in the half of its circumference, it is much less far 
vourably circumstanced for the reproductive process, than a bone deep- 

* Disp. Inaug. 

t Medico- Chirurgical Transactions, Vol. xxi. 



NECROSIS. 103 

ly imbedded in soft tissues, which would readily form the vascular bed, 
or matrix, of the new bone. 

Other circumstances, in the history of necrosis of the shaft of a bone, 
are yet to be mentioned. 

In cases where the periosteum of the original bone is preserved, the 
new bone, being formed upon its internal surface, is invested by it ; 
but in instances where the periosteum of the original bone is in great 
part destroyed, the new bone has for its immediate investment a thick 
layer of dense cellular tissue, which answers all the purposes of peri- 
osteum, transmitting the vessels to the bone, and giving attachment to 
the surrounding muscles, tendons, and fasciae. 

In the walls of the new bone there are holes, of various size and 
number, penetrating to its interior. In the experiments on animals, 
these holes in the new bone are found to correspond with vacancies in 
the periosteum, occasioned by the destruction of portions of it, during 
the inflammatory process immediately consequent on the death of the 
original bone. At a later period of the reparative process, the holes 
in the new bone become continuous with the fistulous passages in the 
soft parts extending to the surface of the limb ; and, consequently, 
they are the ways of exit for the matter, which would otherwise accu- 
mulate around the dead bone. Through these channels, moreover, 
portions of the dead bone are spontaneously discharged, or may be re- 
moved by surgical interference. Whether any of the holes in the new 
bone ever become closed by osseous substance is uncertain. Most of 
them are certainly permanent, but they are productive of no inconve- 
nience, as the soft parts heal soundly over them when the whole of the 
dead bone has disappeared. 

The new bone may consist throughout of cancellous texture, or it 
may be as dense and hard as bone which has been the seat of chronic 
inflammation. Its outer surface is, in general, rough, and presents 
numerous depressions, into which processes of periosteum and the 
vessels enter. The interior of the new bone presents, in some in- 
stances, a medullary tissue, as perfect as in an originally-formed" bone. 
That the new bone possesses the entire apparatus of nutrition, arteries, 
veins, absorbents, and nerves, cannot be doubted. The phenomena it 
presents prove it to be not less perfect in its vital than in its physical 
properties. 

There is a period in the progress of the reparative processes, when 
the articular ends of the origm^l bone are detached from it, but n 



104 NECROSIS. 

yet so firmly connected with the newly-formed bone as to resist the 
action of the surrounding muscles. Under such circumstances, the 
articular ends of the bone may become approximated, and, if allowed to 
remain so, the new bone will be deficient of its proper length. In 
some instances it has been so to the extent of several inches. More 
serious consequences have ensued from the spasmodic action of the 
muscles around the separated shaft of the bone forcing its pointed ex- 
tremity into a contiguous joint, or into a large blood-vessel. Thus, in 
one instance, the pointed extremity of the femur was forced through 
the synovial membrane of the knee-joint, exciting such severe inflam- 
mation in it, that the removal of the limb became necessary for the 
preservation of life ; and, in another case, the pointed extremity of the 
femur was forced through the femoral artery, causing profuse hae- 
morrhage, on account of which the limb was amputated. Further, it 
has happened that a small detached piece of dead bone has pene- 
trated a large artery contiguous to it. Of this occurrence the follow- 
ing instance is recorded: A young man, who had long suffered from 
necrosis of the lower part of the femur, with fistulous passages leading 
to the dead bone, experienced, whilst dancing, a sudden uneasiness in 
his thigh, and, on looking down, observed his trousers to be stained with 
blood, which was found to have issued from the fistulous orifices. The 
haemorrhage was arrested, but it several times recurred. At length, on 
the occurrence of a free flow of arterial blood, the femoral artery was 
tied in the upper third of the thigh. The haemorrhage did not recur, 
but gangrene appeared in the limb, and rapidly extended through it to 
the groin, from which the patient sunk. On examining the limb, a slit 
was found in the popliteal artery, and close to the slit lay a portion of 
bone which was jagged, thin, and sharp.* 

There is so much uncertainty with respect to the time required for 
the reproduction of the shaft of a bone, that on this point no definite 
statement can be made. In most cases, necrosis of the shaft of a bone 
commences in early life, and the reproductive process is completed 
whilst the body is growing. In instances where the process of repro- 
duction advances so slowly that it extends through several years, the 
growth of the limb is not interrupted, the new bone increasing in length 
and thickness proportionately to the rest of the limb. 

The cases of necrosis most favourable for the reproductive process, 
are those in which the bone suddenly, and at once, completely per- 

* Dublin Journal of Medical Science, Nov. 1835. 



NECROSIS. 105 

ishes, and in which, besides, there has been no interference with the 
consequent inflammation in the periosteum and surrounding parts, con- 
stituting the first stage of the reproductive process. When the bone 
has very slowly perished, or when its death has been preceded, or is 
accompanied by, morbid changes in its tissue, or in the surrounding 
soft parts, the reproductive process will probably fail. One of this 
class of cases of necrosis in the tibia, was under the care of Mr. 
Parker, in the Radcliffe Infirmary, Oxford. The patient was a female, 
seventeen years of age, and the disease had been two years in progress 
when the leg was amputated. The middle third of the shaft of the 
tibia had perished, and this was accompanied by widely-spreading ul- 
cerations in the surrounding soft parts. The dead bone separated from 
the living bone, and it was removed by operation ; but no new bone 
formed in its place. The limb became useless, the ancle and foot 
hanging like those of a paralytic-leg, or of a leg with an ununited frac- 
ture. Under these circumstances the limb was amputated, and, on 
examining it, there was found, in the space between the upper and low- 
er portions of the tibia, only a thick cord of dense fibro-cellular tissue, 
of the same character as the tissue, which, in most un-united fractures, 
is found in the space between the ends of the bone*. 

In these instances of necrosis, it is probably owing to the diseased 
condition of the soft parts around the dead bone that the new bone is 
not formed, The reproductive process, in consequence, advances only 
to the formation of a dense fibro-cellular tissue ; it fails in the com- 
pleting stage, which is the development by ossification of this tissue 
into bone. 

Necrosis, followed by reproduction, in any of the flat bones, is rare ; 
in some of them it never occurs ; for example, in the flat bones of the 
cranium, as would be expected, from the consideration of the- differ- 
ence in the relations of the pericranium and dura mater to the cranial 
bones from those of periosteum to other bones, the pericranium having 
no tendency to form new bone, and the dura mater having this tenden- 
cy in a very limited degree ; here, moreover, there is no stratum of 
soft vascular tissue, to serve as the matrix of reproduction. There 
have been instances of reproduction of portions of the ilium and of the 
scapula. 

Necrosis of the ilium is frequently observed ; but it rarely occurs 
under circumstances favourable to the reproductive process ; and for 

* The amputated limb was presented by Mr. Parker to the museum of St. Barthol- 
omew's Hospital, First series, No. 260. 



106 NECROSIS. 

other reasons it always constitutes a serious, and mostly an irreparable, 
disease. The exfoliation of the dead bone here advances very slowly, 
and frequently it is never completed. I have seen several of these 
cases, in which the dead bone had continued for many years, appa- 
rently unchanged, with the open fistulous passages leading to it. 
When the posterior parb of the ilium has perished, occasioning the de- 
struction of its articulation with the sacrum, a complication of disease 
is thus produced, the reparation of which is scarcely to be expected ; 
for, without the exfoliation and reproduction of the bone that has per- 
ished, there can be no anchylosis of the ilio-sacral articulation, and, 
consequently, no restoration of firmness -to the walls of the pelvis. 
Rather it is to be "expected, that, as in the following case, the vital 
powers will sink from the irritation of the disease. A middle-aged 
man was admitted into St. Bartholomew's Hospital, on account of 
severe pain in the lower part of the back, which was consequent on the 
effort of lifting a heavy weight. Fluctuation becoming perceptible on 
the back part of the pelvis, an incision was here made, giving outlet to 
matter ; and at the bottom of the abscess, the rough and denuded sur- 
face of the ilium was discovered by a probe. An issue was opened 
near the diseased parts, which relieved the pain : every effort was 
made to assist the reparation of the disease by strengthening the sys- 
tem, but to no purpose. After lying in the hospital several months, he 
died. On examination, I found necrosis of the posterior part of the 
ilium, with the destruction of its articulation to the sacrum, and there 
was no separation of the dead bone. 

It is doubtful whether any of the short cylindrical, or irregularly- 
shaped, bones are ever reproduced.* 

Instances of necrosis in early life have occurred, wherein a small 
portion of the dead bone, not separated from the living bone, has re- 
mained unchanged for many years, and the fistulous passages in the 
soft parts leading to it have become closed. Under these circum- 
stances, the patient has presumed upon the sound condition of the 
parts ; but, after the lapse of some time, it may be a year, or longer, 
a fresh attack of inflammation, followed by abscess and the re-opening 
of the fistulous passages, has shown that the original source of irrita- 
tion still existed. But the complete cicatrization of the soft parts over 
dead bone, however small its extent, is a rare occurrence, and it 

* Ossa brevia sive cuboidea, quantum ego quidem indagando assequi potui, nunquam 
regenerantur. Weidmann de Necrosi, p. 31. 






NECROSIS. 107 

probably occurs only in the instances where the separation of the dead 
from the living bone has failed to take place. When the dead bone is 
detached from the living bone, it becomes as a foreign body, an irritant 
to the adjacent parts ; purulent fluid is in consequence formed around 
it, the outlet for which is the fistulous passages in the surrounding soft 
parts. So long, therefore, as this suppuration continues, the fistulous 
passages are sure to remain open. But, on the other hand, a small 
piece of dead bone, retaining its connexion with the living bone, may 
excite so little irritation in the surrounding parts, that no suppuration 
from them ensues, and, under such circumstances, it is not unlikely 
that the fistulous passages leading to the dead bone may become closed. 
There are instances of necrosis in which portions of new bone, are 
found closely united to the exterior of the dead and exfoliated bone- 
And it may be doubtful how this happened ; it may have been, that 
inflammation of the bone was followed by the deposit of osseous sub- 
stance upon its surface, but that this new osseous substance was of 
unhealthy character, and that, in consequence, it perished with the 
original bone ; or the new osseous substance may have been deposited 
from the surrounding tissues upon the dead bone, in the manner that 
this occurred in the experiments of Mr. Gulliver, already noticed, in 
which pieces of dead bone were introduced into the medullary tubes of 
the bones in rabbits ; and, on examining the limbs some time after- 
wards, the dead bone was found to be adherent to the living bone by 
new osseous substance, having the composition of true bone*. An il- 
lustration of these phenomena occurred in a remarkable case of ne- 
crosis of the lower jaw, recorded by Mr. Perry. The entire jaw was 
removed by operation, and it was found enclosed in a new case, con- 
sisting of grey, porous, osseous substance, evidently of an unhealthy 
character. Nearly all the teeth remained in the mouth, and were 
kept together by their connexion with the gum. Mr. Perry and my- 
self visited this patient six months after the removal of the lower jaw. 
We found her in good health, but there was no reproduction of the 
bone. I introduced my finger between her grinding teeth, and found 
that she could firmly bite it. She stated, that she chewed her food by 
a movement of the upper jaw, aided by the action of the tongue, in 
rubbing the morsel against the teethf . 

* Medico- Chirurgical Transactions, Vol. xxi. 

t This remarkable specimen of necrosis of the lower jaw was presented by Mr. 
Perry to the museum of St. Bartholomew's Hospital, First series, No. 168. History of 
the case, Medico-Chirurgical Transactions, Vol. xxi. 



108 NECROSIS. 

The following are references to some of the least frequent examples 
of the reproduction of bone, consequent on necrosis : — 

Lower jaw. In a girl, aged ten years, the whole ramus of the jaw, 
with its condyle and coronoid process, was extracted by Desault. Its 
place was supplied by regenerated bone, possessing the same solidity 
as the rest of the jaw, and its motions were equally perfect. " Chi- 
rurgicalJournal," Vol. ii. 

Separation of the ramus with the entire condyle. Recovery with- 
out alteration of the shape, or diminution of the mobility of the jaw. 
Clinical Report, by James Syme, Esq., in the " Edinb. Medical and 
Surgical Journal.' ' 

Scapula. Scapulam mortuam excidisse et regeneratam fuisse est 
vir clarus Chopart. " Weidmann de Necrosis," p. 28. 

Clavicle. Necrosis of the clavicle in its whole extent, followed by 
the formation of a new bone, and the perfect recovery of the power of 
the arm. " Mem. de l'Acad. Royale de Chirurgie," Tome v. 

Necrosis of the clavicle, consequent on a fall upon the shoulder. 
The dead bone was extracted through a fistulous opening ; it compris- 
ed the sternal end, and nearly the whole length of the clavicle. The 
bone was completely reproduced. " Repertoire d'Anatomie et de Phy- 
siologie," Tome ii. 

Sternum. Necrosis of a great part of the sternum. Reproduction 
of it was in progress. Museum of St. Bartholomew's Hospital, First 
series, No. 63. 

Femur. Necrosis and exfoliation of the neck with the shaft of the 
femur in a child. The recovery was so perfect, that the limb became 
firm, and was but little shortened. Museum of St. Bartholomew's 
Hospital, First series, No. 204. 

Fibula. Necrosis of the shaft of the fibula. Reproduction of it 
perfect. Museum of St. Bartholomew's Hospital, First series, No. 
158. 

TREATMENT OF NECROSIS. 

In the treatment of superficial necrosis, two considerations arise ; 
namely, can any thing be done to accelerate the exfoliation of the dead 
bone ? and, should it be removed by operation ? 

In general, the best applications to the soft parts around dead bone 
are those of a soothing nature. There are, however, instances of su- 



NECROSIS. 109 

perficial necrosis, in -which stimulant applications appear to be servicea- 
ble, by producing moderate excitement in the parts, which is favoura- 
ble to the process of exfoliation, just as a slough in soft parts separates 
rapidly or otherwise, according to the degree of surrounding inflamma- 
tion. For this object, mercurial ointment, mixed with soap cerate, is a 
suitable application. But the stimulant selected must not be powerful, 
since it might then have the eiFect of extending the necrosis, by excit- 
ing inflammation in the surrounding living bone. Another means of 
expediting exfoliation is to produce excitement in the parts around the 
dead bone, by exercise of the muscles of the limb in which the necro- 
sis is situated. Thus, in a case of superficial necrosis of the tibia, I 
have often observed the exfoliating process to be stationary, whilst the 
limb was at rest ; but that, when its muscles were put into constant 
action, activity in the exfoliating process was manifested. The consti- 
tutional influence of mercury has, in some cases, appeared to hasten 
exfoliation ; and, accordingly, in instances of its unusually slow pro- 
gress, mercurial ointment applied to the limb may be serviceable, as 
much by its constitutional influence as by its direct action on the parts 
around the dead bone. - 

In former times it was the practice to make applications to the dead 
bone itself, with the view of hastening its exfoliation. The actual cau- 
tery and the mineral acids were employed for this object. It has also 
been recommended that the dead bone should be softened by the appli- 
cation of a mineral acid to it, preparatory to its being scraped away. 
I have witnessed the application of nitric acid in this view ; it render- 
ed the bone porous, but did not appear to hasten its exfoliation. I 
have also witnessed the effect of the application of dilute muriatic acid 
to the surface of a tibia which had perished from syphilitic disease. 
The patient had been salivated, and the ulcer around the dead bone- 
became healthy ; but as its separation was not apparently advancing, 
lint soaked in dilute muriatic acid was applied to it, and frequently re- 
newed, a thick layer of wax being placed around the dead bone to 
prevent the extension of the acid to the soft parts. As the surface of 
the boile became softened it was scraped away, and this was continued 
until the greater part of the thickness of the walls of the tibia was re- 
moved. But it was doubtful whether the proceeding had been advan- 
tageous, for several months afterwards there was still a thick border of 
dead bone circumscribing the excavation made by the acid. 

It appears to have been the practice of M. Delpech to apply dilute 
sulphuric acid to dead bone, with the view of softening it and expedit- 

10 



110 NECROSIS. 

ing its separation*. But, for this object, muriatic acid is preferable. 
If a piece of bone be immersed in dilute sulphuric acid, a crust of sul- 
phate of lime will be formed on its surface, and its vascular and me- 
dullary canals will become filled with the same substance ; in this way 
the further penetration of the bone by the acid liquor will be resisted, 
and the softening of it in consequence prevented. The application of 
potassa fusa, or of nitric acid, to dead bone is a safe proceeding ; and, 
in some cases of superficial necrosis, it has appeared to accelerate the 
exfoliation of a thin layer of dead bone, by the excitement it occasion- 
ed in the contiguous living parts. 

In instances of superficial necrosis occurring in bones which have a 
thin covering of soft parts, the removal of the dead bone by operation 
is expedient when, after a considerable time, the exfoliation does not 
appear to be advancing. The front of the tibia is best suited for such 
a proceeding, and it is here most frequently required. The extent to 
which the surface of a bone has perished is shown by the extent to 
which the soft parts have separated from it ; but this wil not indicate 
the depth of the necrosis. On this point there must be uncertainty, 
and, accordingly, I have known instances of an, operation being under- 
taken, with the expectation that the necrosis comprised only a thin lay- 
er of the bone, when it was found that the entire thickness of its walls 
had perished. 

In internal and deeply-situated necrosis, when a probe, passed through 
the fistulous passage in the walls of the bone, discovers the dead bone 
to be loose, the removal of it by operation is expedient ; and it may be 
so even when the dead bone is not completely separated, on the ground 
of the tediousness of its exfoliation. But, under such circumstances, 
there will be difficulty in distinguishing the dead from the living bone 
at the bottom of a deep cavity, constantly filling with blood, and, con- 
sequently, the whole of the dead bone may not be removed. But the 
excitement of the operation in the surrounding parts will have the ef- 
fect of expediting the exfoliation of the remaining portion of the dead 
bone. 

If the fistulous passage in the walls of a bone leading to the perish- 
ed portion of its inner lamellae, or cancellous texture, is of sufficient 
extent, the dead bone may be extracted through it ; but the enlarge- 
ment of this passage is usually requisite, and it is difficult to do this 

* Journal de la Societe de Medecine de Bourdeaux. Souvenirs de la Clinique de 
Delpecb.. 



NECROSIS. Ill 

when, from the long-continued irritation of an internal sequestrum, the 
walls of the bone have become thickened and indurated. Then, more- 
over, the periosteum, with the .surrounding cellular tissue, being also 
thickened, its separation from the bone, preparatory to the perforation 
of its walls, will not easily be effected. 

With respect to the operative proceedings in these cases, it is only 
necessary to observe further, that in superficial necrosis, the first ob- 
ject will be the division and separation of the soft parts to a sufficient 
extent to allow the removal of the dead bone ; and that, in internal 
necrosis, the hole already existing in the walls of the bone should be 
the centre of the incision through the soft parts, the requisite portion 
of its walls being then removed by a trephine, or other suitable instru- 
ment. In internal necrosis, no more of the bone should be taken away 
than is necessary to allow the removal of the sequestrum from its inte- 
rior, as the vacant space in its walls will become filled by only fibro- 
cellular tissue. Under such circumstances, if the tibia is the bone 
upon which the operation has been performed, its strength might not 
afterwards be sufficient for the support of the body. A single aper- 
ture, of no great size, in the walls of a bone may be sufficient for the 
extraction of a large sequestrum, provided it be conveniently situated 
for the passage of cutting forceps, by which the dead bone may be di- 
vided into two or more pieces. Dieffenbach suggests, that the seques- 
trum be broken by Heurteloup's stone-crushing forceps* ; and I saw 
Dupuytren, in the Hotel Dieu, apply Civiale's branched stone-perfora- 
tor to a sequestrum in the femur ; with the branches of the instrument 
he fixed the dead bone whilst he drilled it with the perforator. It is 
well to know, that the various instruments for perforating and crushing 
stones in the bladder have been employed to facilitate the extraction of 
sequestra, as a case may occur in which some of these instruments 
might be found useful. It is however certain, that the cutting forceps, 
of various sizes and shapes, are generally well suited to effect the divi- 
sion of the dead bone, for the purpose of facilitating its extraction. 

In the treatment of necrosis of the shaft of a bone, in its first stage, 
the object is, to diminish the severity, and check the progress, of the 
inflammation in the surrounding soft parts. It is desirable that the in- 
flammatory action should terminate in the effusion of serum, or of 
fibrin, rather than in suppuration ; it is also desirable that the inflam- 

* Operative Chirurgie, Cap. i. sec. ir. 



112 NECROSIS. 

mation should be confined to the neighbourhood of the dead bone, and 
especially, that it should not extend to any of the contiguous joints. 
In instances of necrosis of the shaft of the femur, from the neglect of 
sufficiently active treatment at the commencement of the disease, I 
have witnessed the extension of inflammation to the knee-joint, followed 
by suppuration in it, with the destruction of its soft tissues, and its 
permanent anchylosis. A strict antiphlogistic treatment is to be con- 
tinued, until the local inflammation and the accompanying fever are ar- 
rested. Perfect quietude of the limb should be observed. It may be 
necessary to abstract blood from the parts, freely and repeatedly, by 
leeches ; and, owing to the severity of the accompanying fever, gene- 
ral depletion may be requisite. Poultices and fomentations are the 
best applications to the limb, and saline and antimonial medicines the 
suitable constitutional remedies. 

If, by the foregoing treatment, the inflammation in the parts around 
the dead bone does not quickly subside, suppuration is to be suspected^ 
and may be indicated by shiverings. In some cases, suppuration com- 
mences beneath the periosteum ; the matter thence penetrating the sev- 
eral textures of the limb to the skin. In other cases, suppuration com- 
mences in the cellular tissue between the muscles. Wherever the mat- 
ter is situated it should be freely discharged, by one or more incisions ; 
and care must afterwards be taken that the openings are sufficiently 
free, and conveniently situated, for the escape of the matter, that it 
may not accumulate in any part of the limb. 

Upon the subsidence of the inflammatory processes, the thickening 
and consolidation of the tissues of the limb will be maintained by the 
irritation of the dead bone. If there should be constant pain deep in 
the limb, with occasional attacks of inflammation in the surrounding 
parts, counter-irritation, by an issue, is then indicated ; and it may re- 
quire to be continued so long as the source of irritation, namely, the 
dead bone, remains. The counter-irritant will relieve the pain ; and, 
by bringing the parts into a quiet state, it will permit the free exercise 
of the limb, and thus relieve the patient^ from a tedious confinement, 
to the injury of his health. Moderate exercise of the limb is certainly 
favourable to the activity of the reparative processes, which will ad- 
vance more rapidly to their completion than when the limb has been 
kept throughout in a state of inaction. 

Through the early stages of necrosis of the shaft of a bone, atten- 
tion is requisite to the position and length of the limb. The dead bone 
is often detached from its articular ends before the new bone has ac- 



NECROSIS. 113 

quired firmness. The support of splints is then required, to prevent 
shortening of the limb by the action of its muscles. 

The next question is, under what circumstances, in necrosis of the 
shaft of a bone, is it expedient to undertake the removal of the dead 
bone by operation. 

At the period when the shaft of the bone is separated from its artic- 
ular extremities, the formation of the new bone is, in general, so far 
advanced that it forms an osseous case, enclosing the dead bone. For- 
merly, the absorption of the dead bone was relied upon as the means of 
its removal. But the observations upon this subject, in modern times, 
have rendered the doctrine of the absorption of exfoliated bone no 
longer tenable ; and, consequently, the consideration of its removal by 
operation has become more important. 

The perforation of the walls of the newly-formed bone is obviously 
requisite for the removal of the dead bone enclosed within it ; and it 
has been suggested, that this should be done at an early period, when 
the new bone has not yet acquired the hardness of texture which, at a 
later period, will render the perforation of it difficult. But the remo- 
val of the dead bone, at this period, is open to the objection that the 
operation will probably be unsatisfactory, for, as the line of separation 
of the dead bone is not yet completed, its exact limits will not be dis- 
tinguishable at the bottom of the deep cavity in which the dead bone is 
lodged ; and, under these circumstances, there will be a risk, either of 
leaving some of the dead bone, or of removing part of the living bone 
with it. 

The preliminary step to the operation of removing the dead bone is 
to ascertain that its separation is completed, and this may be evident 
by its looseness and mobility. But the exfoliated bone may still be 
firmly fixed by the surrounding granulations becoming closely imbed- 
ded in the excavations of its surface. On this point, Dupuytren offer- 
ed the following suggestion, — that, with the end of one probe resting 
against the dead bone, a second probe should be introduced into another 
of the fistulous passages, and its end pressed against the dead bone : 
if this be movable, it will be made evident by the impressions commu- 
nicated through the probe which was first introduced. 

No rule can be laid down, either for the extent, or direction, of the 
incisions required for the extraction of the dead portion of the shaft of 
a bone. Usually the incisions are made in the interspaces of the fistu- 
lous passages leading to the dead bone ; and in situations where incis- 

10* 



114 NECROSIS. 

ions of the soft parts cannot be safely made, dilatation of the fistulous 
passages, by sponge-tents, may render the incisions unnecessary ; or, at 
all events, be the means of diminishing their extent. At the period 
when the operation for the removal of the dead bone is generally per- 
formed, the soft parts investing the new bone, are consolidated togeth- 
er, very dense, and, besides, acutely sensible, very vascular, and firm- 
ly united to the bone : hence, the incisions through these parts, and 
the separation of them from the bone, must be expected to be a diffi- 
cult task, and very painful, and to be followed by profuse haemorrhage 
from the divided vessels. 

Attention should be directed, in these operations, to the point of re- 
moving as little as possible of the walls of the new bone, as there will 
be no reproduction of it ; and if, in the instance of the femur or the 
tibia being the seat of necrosis, much of the newly-formed bone were 
removed in the operation of exposing and extracting the dead bone, the 
;limb might thereby lose so much of its strength as not firmly to sup- 
port the weight of the body. 

Necrosis of a portion of the cancellous texture within the head of 
the tibia, is a case in which the question of removing the dead bone, 
by operation, is likely to arise. Through the several years which this 
disease usually occupies, there is rarely, for any length of time, a com- 
plete exemption from pain ; attacks of inflammation, many times recur- 
ring in the periosteum covering the head of the tibia, and in the knee- 
joint, and abscesses bursting around the head of the tibia, with puru- 
lent discharge from the fistulous passages leading to the interior of the 
bone, altogether clearly enough indicate the source of the mischief to 
! be a perished portion of the cancellous texture within the head of the 
tibia ; and, at the same time, suggest the extraction of the dead bone 
■by operation, as the proper, and, indeed, the only means of relief. It 
is most desirable that this should be done in the early stage of the dis- 
ease, before destructive inflammation attacks the knee-joint, and before 
.any of the fistulous passages, either within the bone or in the adjacent 
^soft parts, have formed a communication with the joint. If, however, 
•the case is decided to be a fit one for the perforation of the head of the 
tibia, difficulties are to be anticipated in the extraction of the dead 
bone, and from the following causes : — 

In some instances the piece of dead bone, within the head of the 
tibia, is situated so near the upper articular surface that its removal 
would not be practicable without opening the joint. It is, moreover, 
often impossible to determine with certainty the precise situation of the 



NECROSIS. 115 

dead bone, so that the perforation of the head of the tibia shall directly 
lead to it. The fistulous passages are not always a direct guide to the 
dead bone ; occasionally they extend circuitously through the head of 
the tibia, either in a vertical or horizontal direction ; and often they 
open upon either the front, or side, of the tibia, at a considerable dis- 
tance from the spot where the dead bone is situated. When the knee- 
joint has become extensively diseased, and the health of the patient is 
enfeebled by long suffering, then, in considering the difficulties likely 
to arise in extracting the dead bone, amputation of the limb may, 
under such circumstances, be deemed preferable to the hazardous 
and uncertain measure of the perforation of the head of the tibia ; 
it was so deemed in two cases of this kind which I had in St. Barthol- 
omew's Hospital. 

Among the long bones, operations, for the extraction of perished 
portions of the shaft of the bone, are, in general, performed with the 
least difficulty upon the tibia, because here the operation is usually 
undertaken when the front part of the new walls of the bone are, as 
yet, so incompletely formed, that only some narrow, bridge-like, por- 
tions of the new bone will require to be divided, and in part removed, 
to allow the extraction of the dead bone. 

In the humerus, operations for the removal of dead and exfoliated 
portions of its shaft are occasionally required. The cylinder of the 
new bone may be completely formed : but, provided that the dead 
bone within it is loose, its extraction can, in general, without much 
difficulty, be effected. The proceeding here necessary will probably be 
to enlarge one of the holes in the walls of the new bone, and then to 
facilitate the extraction of the dead bone by dividing it with the cut- 
ting forceps into two or more pieces, and the passage to the dead bone 
should be formed in the front and outer part of the arm, where there 
will be no interference with the principal vessels and nerves. In the 
instances of necrosis of the humerus requiring these operations, gen- 
erally the bone has perished from some constitutional influence, inde- 
pendently of any local injury, or disease, and in } r oung persons ; con- 
sequently, the soft parts of the limb are healthy, and the reparative 
processes following the operation usually proceed so vigorously, that 
however large the incisions, for the removal of the dead bone, may 
have been, and however much of the new bone it may have been 
necessary to take away, for the purpose of getting at and extracting 
the dead bone, yet the recovery of the limb will be rapid and com- 



116 NECROSIS. 

plete, the arm becoming, in every respect, sound and efficient for all 
its offices. 

There are no cases of necrosis more difficult to deal with, in respect 
to the question of operation for the removal of the dead bone, than 
those of its occurrence in the lower part of the femur, just above the 
condyles. Here the necrosis is usually consequent on local injury by 
violence. Great enlargement of the limb ensues in the seat of the 
necrosis, produced, in part, by thickening and consolidation of the soft 
tissues immediately around the bone ; and in part, by changes in the 
bone itself, consisting in either the thickening of its walls, or the forma- 
tion of new bone to supply the place of that which has perished. Fre- 
quently the inflammatory processes around the diseased bone extend 
to the knee-joint, giving rise to its partial anchylosis, by either the 
adhesion of its synovial surfaces, or the rigidity of the tissues around 
it. Moreover, the fistulous passages in the soft parts are often so situ- 
ated, that, in taking them as the guide for the incisions to the dead 
bone, the femoral vessels will be endangered, and, not improbably, the 
knee-joint opened. Such are the considerations which, in several 
of these cases that I have seen, led to the conclusion that, in prefer- 
ence to undertaking a protracted operation for the removal of the dead 
bone, with the uncertainty of effecting it, and with the risk of doing se- 
rious mischief in the attempt, it is better to amputate the limb. 

The treatment of necrosis in the bone of a finger or toe, in former 
times, was t3 amputate the part ; but modern experience has suggested 
a better mode of proceeding in these cases. In necrosis of the first or 
second phalanx of a finger, the proper proceeding is, to divide the soft 
parts covering the dead bone sufficiently to permit its extraction* 
The bone will not be reproduced, and, consequently, as happens from 
scrofulous disease in one of the phalanges, the finger will become short- 
ened, but it will still be useful. So likewise, in necrosis of the last or 
ungual phalanx ; instead of amputating the end of the finger, or toe, a 
division of the soft parts should be made to alloiv the extraction of the 
dead bone. The finger will become a little shortened, but the nail will 
remain, and the bulbous form of the end of the finger be preserved, 
whereby it will be far more useful than it would be after the amputa- 
tion of the last phalanx. A small fistulous orifice in the end of the 
finger or toe is the indication that a part, or the whole, of the ungual 



NECKOSIS. 117 

phalanx has perished. By means of a thin probe the dead bone may- 
be detected, but not in every instance ; still, however, the long per- 
sistence of a fistulous passage in the end of a finger or toe, is to be 
regarded as sure evidence of the existence of either dead or diseased 
bone. Without clear evidence of the diseased bone having perished 
and exfoliated, it would be preferable to amputate the phalanx, as was 
done in the following case, communicated to me by my friend, Mr. 
Ormerod, surgeon to the Raclcliffe Infirmary, Oxford. The end of the 
finger was pierced by a needle, which it was thought had probably 
pricked the bone. An ulcer formed on the finger, which could not be 
made to heal. When it had lasted a year and a half, the phalanx was 
amputated ; and on examining the bone, a fistulous canal was found 
extending through it, but there was no dead bone. The disease here 
had evidently been abscess within the ungual phalanx, consequent on 
injury. 

The following are illustrations of the operative proceedings required 
for the removal of dead bone. 

Necrosis of part of the inner to all of the Tibia, consequent on 
Fever. A man, twenty-seven years of age, had disease in his leg, 
which commenced two years previously in Ceylon. He there suffered 
an attack of fever, and, about six weeks after the recovery from it, a 
small swelling formed on the front of the tibia, about one-third from 
the ancle ; it burst in two places, and the two openings had remained, 
constantly discharging foetid matter, to the present time. A probe 
introduced into each opening readily penetrated a channel in the front 
walls of the tibia, and at a considerable depth, passed over rough, but 
not loose, bone. I made a longitudinal incision, about four inches in 
extent, along the front of the tibia, and crossed it with a transverse 
incision ; and then separated the thickened and indurated soft parts 
from the bone, to which they were firmly adherent. The surface of the 
bone was rough, and it bled so freely as to show great increase of its 
vascularity ; further, two channels were observed in the walls of the 
bone corresponding with the two fistulous openings in the investing 
soft parts. With a trephine I removed part of the front walls of the 
tibia, and enlarged the opening with a small saw. The interior of the 
tibia being thus exposed, it appeared to be filled with tough and very 
vascular granulations; but on removing some of these, a surface of 
dead bone was recognized, consisting of the inner lamellae of the pos- 
terior walls of the tibia. The dead bone was removed. The pain of 
the operation was very great, but it was followed by scarcely any con- 



118 NECROSIS. 

stitutional disturbance. In a few days, healthy granulations arose 
from the whole of the exposed surface of the bone, except at one spot, 
where it was discovered that a portion of the perished inner lamellae of 
its posterior walls still remained. For its removal, it was necessary to 
take away another small portion of the front walls of the tibia. Af- 
terwards, the whole cavity of the bone became filled with healthy 
granulations ; and in about two months from the operation, the wound 
had completely healed. 

Necrosis of part of the inner ivall of the Tibia, consequent on 
Fever. A man was admitted into St. Bartholomew's Hospital on 
account of disease in his leg, which had commenced three years pre- 
viously in the West Indies, immediately after an attack of fever. His 
suffering had been severe, and almost constant. A fistulous orifice in 
the soft parts led to a narrow channel, extending through the front 
walls of the tibia to its medullary tube within which a loose piece of 
dead bone was discovered. The channel in the walls of the tibia was 
so narrow, that, in order to get at the dead bone, its enlargement was 
necessary ; and this was not easily effected, on account of the thick- 
ened and hardened state of the bone, which rendered the perforation 
of it extremely difficult. But, when the perforation was accomplished-, 
the dead bone was easily removed, and it appeared to be part of the 
inner wall of the tibia. The cavity in the bone became filled with 
healthy granulations, and in a short time the leg was perfectly sound. 

Necrosis of part of the inner wall of the Tibia, consequent on In- 
jury. This case was similar to the foregoing, except that the death 
of the inner wall, and cancellous texture of the tibia, was consequent 
on the penetration of the bone by a steel arrow, in the East Indies. 
Here, also, much difficulty was experienced in perforating the thick- 
ened and indurated front walls of the tibia, to effect the removal of 
the dead bone from its interior. 

Necrosis of part of the cancellous texture of the Tibia, in a young 
person. In the case of a boy, who had been several months in St. 
Bartholomew's Hospital, with a small ulcerated hole in the front of the 
leg, freely discharging matter, it was at length suspected the bone 
might be unsound ; but it was not until the parts had been repeatedly 
examined with a probe, that a minute channel was discovered in the 
front walls of the tibia, extending to its medullary cavity. This was 
considered to be sufficient ground for believing that part of the cancel- 
lous texture, and, probably, of the inner wall of the tibia, had perish- 
ed. Accordingly, I perforated the front of the tibia, and found a por- 



NECROSIS. 119 

tion of its cancellous texture dead and separated. The dead bone was 
easily removed, and the wounded parts healed so quickly, that, in a 
few weeks after the operation, the boy left the hospital with a sound 
leg. 

Necrosis of fart of the shaft of the Femur, consequent on Injury. 
A man was shot in the lower part of the thigh with an iron bullet ; 
since which he had, for several years, suffered constant and severe pain 
in the soft parts around the femur, accompanied by the bursting of nu- 
merous abscesses ; some of which had contracted to fistulous passages 
leading to the bone. His health was much injured from long suffering, 
and he solicited the removal of the limb. As, however, he referred to 
one spot at the lower part, and outer side, of the thigh, as the princi- 
pal seat of pain, Mr. Earle here made an incision through the skin and 
muscles. Fortunately, this incision was made directly over a loose por- 
tion of the shaft of the femur, which appeared to have been splintered 
by the bullet. The piece of dead bone, about two inches long and one 
inch broad, was removed. All pain in the thigh afterwards ceased, the 
fistulous openings closed, and the healing of the wound was followed 
by soundness of the limb. 

Necrosis of part of the outer wall of the Tibia. In the following 
case of superficial necrosis of the tibia, the dead bone was removed by 
operation before it had separated from the living bone. 

A middle-aged man was admitted into St. Bartholomew's Hospital, 
with the front surface of the tibia in its whole width, and in two inches 
of its length exposed, and perfectly black. He had received a severe 
blow on the shin, which was followed by destruction of the soft parts 
and the death of the surface of the bone. When he had been in the 
hospital about three months, I examined, with a probe, the circumfe- 
rence of the dead bone, but could discover no groove between it and 
the living bone. As the separation of the dead bone thus appeared 
not to have commenced, the removal of it by operation, was considered 
to be a proper measure. Accordingly, with a trephine and chisels, I 
removed the whole of the dead bone, which comprised only the outer 
lamellae of the front walls of the tibia, and did not extend to its medul- 
lary cavity. The exposed surface of the living bone bled freely, and 
was very acutely sensible. From this surface of the bone, granula- 
tions quickly sprouted forth, and the wound in a short time was sound- 
ly healed. 

Necrosis of the entire shaft of the Tibia. In St. Bartholomew's Hos- 
pital, under the care of Mr. Lawrence. The necrosis in the whole 



120, NECROSIS. 

shaft of the tibia had commenced a year previously. The limb was 
greatly enlarged by the formation of the new bone. At the upper 
part of the leg, the dead bone was exposed, no new bone being here 
formed over it. At the lower part of the leg, a fistulous passage 
extended through the new bone to the dead bone enclosed within it. 
The space between this passage and the exposed portion of the dead 
bone was occupied by a bridge of new bone, about an inch and a half 
in width. When the exposed dead bone, at the upper part of the leg, 
was pressed, it yielded, thereby indicating that its separation from the 
articular end was here completed. With a probe passed through the 
fistulous passage in the new bone, the same yielding of the dead bone, 
at the lower part of the leg, was observed. The entire shaft of the 
tibia, thus separated from its articular ends, was a source of constant 
pain, and of profuse suppuration from the surrounding parts, seriously 
injuring the general health. Under these circumstances, the removal 
of the dead bone by operation was undertaken. 

An incision being made down the middle of the front of the leg and 
through the greater part of its length, the skin and subjacent soft parts 
were freely separated on each side from the new shaft of the bone ; 
then, with the saw and cutting-forceps, the bridge of new bone, which 
has been described, was divided in two places, so as to permit its re- 
moval. The whole of the dead bone was thus exposed, and, by using 
a little force, it was withdrawn, exposing the layer of very vascular 
granulations forming the lining of the new bone, and the surface of 
these granulations was remarkably smooth and soft. The dead bone 
comprised the whole thickness and nearly the whole length of the shaft 
of the tibia. The cavity from which the dead bone was withdrawn 
soon became filled with granulations, and the formation of the new bone 
proceeded to its completion, giving to the leg firmness, together with 
its natural size and shape. 

Necrosis of the inner wall and cancellous texture of the Tibia. 
This resembles, in some points, a case which has been already related ; 
but it contains other particulars of interest. 

Several years before the admission of the man into St. Bartholo- 
mew's Hospital, the tibia had been penetrated, as in the case already 
related, by a steel arrow in the East Indies, since which his leg had 
been scarcely ever free from pain. The shaft of the tibia had become 
greatly enlarged, and several fistulous passages had formed in its front 
walls, through which many small pieces of bone had been discharged. 
A crucial incision over the front of the leg, and of considerable extent, 



NECROSIS. 121 

enabled me to turn aside four triangular flaps of skin with the subja- 
cent soft parts sufficiently for the free exposure of the bone. Then, 
with a trephine, I removed part of the front walls of the tibia, which 
was very difficultly done, on account of the extreme thickness and 
hardness of the bone : its tissue was besides so acutely sensible, that 
the perforation of it gave the severest pain. - Several small pieces of 
dead bone were removed from the medullary cavity of the tibia. Not- 
withstanding the severe pain and tediousness of the operation, but lit- 
tle inflammation ensued in the surrounding parts, and scarcely any con- 
stitutional disturbance followed it. Granulations quickly arose from 
the whole of the exposed surface of the bone, and they were so exqui- 
sitely sensible, that they evidently partook of the morbid sensibility of 
the thickened and hardened bone. Subsequently, the reparative pro- 
cesses were interrupted by two attacks of erysipelas in the leg, accom- 
panied by inflammation of the absorbents of the thigh and much con- 
stitutional derangement. After the last of these attacks, the man di- 
rected my attention to a yielding of the leg in the situation of the dis- 
ease. This yielding of the bone could not be explained by referring 
to the extent of the walls of the tibia that had been removed : rather, 
it appeared to be owing to a softening of the tissue of the inflamed 
bone*. Notwithstanding the softening of the bone, the wound healed 
soundly. Then, with the view of strengthening the limb, I desired the 
man to move about on crutches, with the weak leg slung in a bandage 
passed around his neck. In this way he improved but little ; at the 
end of three months he could still bear no weight on the leg without its 
yielding. Next, with the view of exciting more action in the muscles 
of the leg, I removed all the bandages from it, and desired the man to 
sit on a table, for a certain time every day, with his legs dependent, 
and then, by the movements of his ancle-joint, to keep the muscles of 
the weak leg in constant action. The good effect of this proceeding 
was soon evident. With the consciousness of increasing strength in 
the limb, he became able to bear the weight of his body on it ; and, on 
leaving the hospital, could walk with the support of a piece of paste- 
board confined to the side of the leg ; and in this condition his leg re- 

* This will perhaps be considered to receive some illustration from the fact, that in 
the treatment of an ununited fracture of the femur by seton, the new osseous substance 
has become softened after the occurrence of attacks of inflammation in the thigh. 
" Case where a seton was introduced between the fractured extremities of a femur, 
which had not united in the usual manner ; by James Wardrop." Medico- Chirurgical 
Transactions, Vol. v. 

11 



122 NECROSIS. 

mained for many years, during which I had several opportunities of 
seeing him. 

Extensive Necrosis of the inner wall of the Tibia. In the following 
case of necrosis of the inner lamellae of the tibia, the result of the opera- 
tion undertaken for the removal of the dead bone, was not satisfactory ; 
but its history will constitute a good record of the circumstances which 
may belong to such a form of disease. I admitted into St. Bartholo- 
mew's Hospital a female, twenty-two years of age, of remarkably fee- 
ble habit, evidenced by the weakness of her pulse, icy coldness of her 
hands and feet, blueness of the face and general emaciation, and by 
the fact, that with the best of diet and medicine but little could be ef- 
fected for the improvement of her health. The disease, on account of 
which she was admitted into the hospital, was a chronic abscess in the 
upper and outer part of the thigh, unconnected with either bone or 
joint. Upon the subsidence of this abscess, she directed my attention 
to two soft and not painful swellings upon the front of her tibia, from 
each of which about two drachms of matter were discharged by punc- 
ture. The matter continued to flow so freely from the punctures, that 
I suspected it came from the interior of the tibia, and, accordingly, I 
examined the bone with a thin probe, which, at the bottom of each ab- 
scess, penetrated a minute canal, extending very obliquely through its 
walls to the medullary cavity. Thus it was ascertained, that the ab- 
scesses upon the front of the tibia were the outlets of matter formed 
within the bone. Through the following several months there was con- 
stant and severe pain in the bone, with repeated attacks of inflamma- 
tion in the soft parts covering it, for the relief of which all the treat- 
ment by leeches, poultices, and lotions, with iodide of potassium and 
sarsaparilla, was but palliative, and only for a short time. Then, in the 
belief that the source of irritation must be the confinement of dead 
bone within the tibia, I made two perforations with a small trephine 
through the walls of the bone, in the situation of the two ulcerated 
passages in them. Through the spaces formed by the trephine, I re- 
moved several small pieces of exfoliated bone, and I hoped that these 
constituted the whole of the dead bone ; but it proved otherwise. The 
pain in the tibia, and the attacks of inflammation in the soft parts cov- 
ering it, recurred as severely as before the operation. In this condi- 
tion she left the hospital, more than a year after her admission, and 
shortly afterwards she died, as I believe, from inflammatory disease in 
her chest. The diseased tibia is preserved in the museum of St. Bar- 



NECROSIS. 123 

tholomew's Hospital*. A section of the bone showed, that necrosis 
and exfoliation of portions of its inner lamellae had taken place in near- 
ly the whole length of the shaft. Around the sequestra the tibia was 
enlarged, partly by expansion of its texture, and partly by osseous de- 
posit on its outer surface. The appearances of the divided tivia were 
such as to indicate, that the seat of the necrosis had not been in its in- 
nermost lamellae adjacent to the medullary tissue, but rather in the 
middle lamellae of the walls ; and, accordingly, the cavities containing 
the sequestra were bounded on one side by the innermost lamellae, and 
on the other side by the thickened outer lamellae of the bone. 

With respect to the treatment of this case, my regret was, that I 
had not for a longer time delayed the applications of the trephine to 
the tibia, whereby sufficient time would have been allowed for the com- 
plete separation of the dead from the living bone, for then, by freely 
perforating the thickened walls of the tibia, I should have succeeded 
in effecting the removal of the whole of the sequestra. 

* First series, No. 261. 



PART II. 



TUMORS OF BONE. 

The morbid growths comprised in the tumors of bone exhibit a great 
variety of characters. Some of them are peculiar to bone ; others 
are analogous to the growths from soft parts. In some of them, more- 
over, the remarkable feature is seen, of the production of tissues iden- 
tical with those which occur in the natural formation of bone. Thus, 
with respect to the cartilaginous, and to some of the osseous tumors, 
the cartilage, in the first, in no way differs from foetal cartilage ; and 
the osseous substance, in the second, presents all the features of healthy 
bone. 

An arrangement of the tumors of bone cannot well be founded on 
the place of their origin, since many of them, identical in nature, arise 
indifferently from periosteum, the compact, or cancellous tissue of bone. 
Often, indeed, concurrently with the growth of a tumor from the out- 
side of a bone, a similar growth arises within it. Nor can an arrange- 
ment of these tumors be easily determined by their composition, two or 
more morbid products being occasionally united in the same tumor. 
Another source of difficulty in classifying the tumors of bone is the 
changes to which they are liable. Thus, some of these tumors, proba- 
bly from weakness of their vital organization, when of large size, soften 
and break up in the centre, leaving only a thin shell of their original 
substance. Again, among certain of these tumors, especially the car- 
tilaginous, fibrous, and osseous, transformations of structure occur ; 
but so far in a definite order, that whilst the osseous do not change 
into the cartilaginous or fibrous tumors, these frequently become con- 
verted into bone. 

Sufficient has probably been stated to explain why a perfect arrange- 
ment, or an unobjectionable classification, of the tumors of bone has 

11* 



126 TUMORS OF BONE. 

appeared to be impracticable. More, therefore, will not be proposed 
on this head than so to group the chief of these tumors as will facilitate 
their individual recognition. And, proceeding upon this view of the 
subject, I shall, in the first place, enumerate the principal products 
found in the tumors of bone ; and then offer a history of certain tu- 
mors which are definite in their characters and progress, and, besides, 
are of interest and importance, from the considerations, practical or 
pathological, belonging to them. 

PRINCIPAL PRODUCTS FOUND IN THE TUMORS OF BONE. 

1. Cartilaginous substance. 

2. Osseous substance, which, in composition and arrangement, may in 
no respect differ from healthy bone ; or may present the general 
characters of ivory ; or may be of a dull white colour and chalk-like 
appearance, and of such composition that it can be readily scraped 
or rubbed into a fine powder. When osseous substance constitutes 
only a part of the tumor, it is usually situated at its base, in the form 
either of a solid mass, or of a sort of frame-work supporting the soft- 
er constituents of which the rest of the tumor consists. 

3. Encephaloid, or brain-like substance. 

4. Fibrous substance. 

5. Gelatinous substance. 

6. Fatty substance. 

7. Soft and very vascular substance, of the character of erectile tissue. 

8. Fluids of various kinds — sanguineous, serous, or gelatinous. 

Other morbid products are deposited in bone ; namely, the materi- 
al of melanosis, and of hard carcinoma, and of tubercle. But these 
are not usually accompanied by enlargement of the bone, or by the 
growth of a tumor from it. Tubercle in bone is considered under the 
head of scrofula. Melanosis and hard carcinoma, in bone are con- 
sidered each by itself, in a separate section. 

The development of entozoa in bone is in general accompanied by 
the enlargement of it in a manner to be properly included among its 
tumors. Accordingly, this subject is considered in the present section. 

The production of simple membranous cysts in bone is also included 
in the consideration of its tumors, as these cysts occasion enlargement 
of the part of the bone in which they are situated. 



TUMORS OF BONE. 127 

1. TUMOR OF BONE COMPOSED CHIEFLY OF CARTILAGINOUS SUBSTANCE : 
ENCHONDROMA (MULLER) OSTEOSARCOMA*. 

This tumor occurs in the early and middle periods of life. Gene- 
rally it grows from a single bone ; but occasionally from several bones 
of the hand or foot. In a case recorded by Muller, cartilaginous tu- 
mors arose from, the bones first of one hand, then of the other, and 
afterwards from the bones of both feet. In a case which occurred at 
the General Hospital, Birmingham, a boy, seventeen years of age, had 
cartilaginous tumors of all sizes to that of an orange, growing from 
almost every digital and metacarpal bone of one hand, and from the 
forefinger of the other. The formation of the swellings commenced in 
his earliest infancy, and they were still increasing, when one hand, 
and the forefinger of the other, were amputated at the same instant 
by Mr. Amphlett and Mr. Crompton, surgeons to the' hospital, the pa- 
tient being under the influence of aether. At the period of the opera- 
tion, the father, mother, one brother, and one sister, of the boy were 
living, and free from any such diseasef. A similar case to the fore- 
going was in St. Bartholomew's Hospital, under the care of Mr. Law- 
rence, in a boy, from whose digital and metacarpal bones in both hands 
numerous cartilaginous tumors had arisen. 

There are two distinct forms of the cartilaginous tumor — one grow- 
ing from the outside of a bone, the other from its interior. In the 
instances of its occurrence in any of the larger bones, as the humerus, 
femur, or tibia, it usually grows from the outside of the bone, rarely 
within it. But, in the instances of its occurrence in the smaller 
bones, especially of the hand or foot, it usually originates within the 
bone. 

When the cartilaginous tumor originates within a metacarpal or 
digital bone, the morbid deposit commencing in the cancellous texture, 

=* The terra osteosarcoma is here introduced for the reason, that, in the records of 
surgery, many examples of the cartilaginous tumor are so designated ; but various 
growths from bone have been comprised in this term. The first clear account of the 
cartilaginous tumor of bone was given by Muller, in his Essay on the Nature of Can- 
cer, and of those morbid growths which may be confounded with it. Translated by 
Dr. West. 

f For the possession of the amputated hand and forefinger I am indebted to Mr. 
Hodgson, Mr. Amphlett, and Mr. Crompton. Museum of St. Bartholomew's Hospi- 
tal, First series, Nos. 262, 263. 



128 TUMORS OF BONE. 

is, in some cases, diffused through it, unaccompanied by pain or any 
change in the coverings of the bone indicative of the disease within it. 
At length, in one part, and it may be on one side only, or in the entire 
circumference, of the bone, its walls expand into a globular tumor, 
consisting of a thin osseous shell, enclosing the cartilaginous substance. 
The tumor, in some instances, remains small, in others it increases to 
the size of an orange. But, however large the tumor may be, it re- 
tains the osseous shell, which grows with the increase of the cartilage 
within it, and even when of its largest size, the tumor is unaccompan- 
ied by pain, or change in the surrounding tissues. 

In the instances of the cartilaginous tumor growing from the out- 
side of a bone, the exterior of the tumor is usually noduled, its car- 
tilaginous substance is disposed in lobes, united by fibrous septa, 
through which the blood-vessels ramify, and a fibrous capsule en- 
closes the tumor. 

The cartilaginous substance composing these tumors is of a blueish 
or greyish-white colour, compact and elastic, but less firm than articu- 
lar cartilage. Chemical analysis obtains from it the same results as 
from pure cartilage. It yields in boiling the peculiar form of gelatine 
designated chondrine, as constituting the base of cartilage, and it pre- 
sents, in the microscope, round or oval corpuscules of the same char- 
acter as those in pure cartilage. 

The cartilaginous tumor is usually of slow growth, and it does not 
affect the general health, even when of large size, unless a disorgan- 
izing process has commenced within it. It is to be regarded as a 
strictly, local disease notwithstanding the instances of its growth from 
several bones of a hand or foot ; for these are so rare as not to inter- 
fere with the conclusion, that the removal of the tumor, whether 
growing from the outside of a bone, or from its interior, will not be 
followed by the growth of similar tumors elsewhere. 

The discrimination of the cartilaginous tumor of bone has been 
found difficult when one is situated upon the humerus or femur, from 
-ithe thick layers of muscle enveloping it. Its discrimination is less 
'difficult when situated upon the bone of a finger, where it forms a firm, 
painless, smooth, and globular, or noduled swelling closely attached to 
the bone. But the difficulty here occurs of determining whether the 
growth is from the outside of the bone or from its interior, since the 
immobility, and other characters of the tumor, are in each case the 
same, and yet the distinction is important, as it affects the question of 
removing the tumor alone, or with it the bone in which it has arisen. 



TUMORS OF BONE. 129 

Some help to this diagnosis is furnished in the fact, that when there is 
only a single cartilaginous tumor growing from a finger or toe, its more 
common origin is from the outside of the bone ; but when there are 
several cartilaginous tumors, they usually originate within the bone. 
In the instances of the origin of the cartilaginous substance within the 
bone, it is in general diffused through its cancellous texture beyond the 
limits of the external tumor, and accordingly it is necessary to take 
away the whole of the bone to ensure the complete removal of the 
disease. ' 

When the cartilaginous tumor has acquired a large size, it is in gen- 
eral stationary, in respect to its growth and structural condition ; but, 
in some instances, a disorganizing process has ensued in the tumor, 
accompanied by the following phenomena — enlargement of the sub- 
cutaneous veins ramifying upon it, softening of its central substance, 
ulceration of its coverings, excavation of its centre by sloughing and 
ulceration, accompanied by a profuse discharge of serous and foetid 
fluid from an ulcerated passage in the soft parts investing the tumor. 
Such was the progress of a cartilaginous tumor arising from the hu- 
merus of a man fifty-five years of age, who was a patient in St. Bar- 
tholomew's Hospital*. In some cases, a cavity has formed in the cen- 
tre of a large cartilaginous tumor, containing several pints of a viscid 
honey-like fluidf. In an instance recorded by Sir P. Crampton, a 
cartilaginous tumor, growing from the femur, measured six feet six 
inches in circumference, and in its centre there was a cavity contain- 
ing several quarts of brownish fluid, apparently the result of the disor- 
ganization of the cartilaginous substance J. 

There is evidence to prove, that the cartilaginous tumor of bone, 
when of small size, may be influenced by local remedies ; that by ap- 
plying to it preparations of iodine or mer cury, or of both conjointly, 
the gradual dispersion of the tumor may be effected. 

A female, aged twenty-eight, was admitted into St. Bartholomew's 
Hospital, with a round tumor, the size of a hazel-nut, projecting from 
the front of the superior maxillary bone, just above the sockets of the 
canine and bicuspid teeth ; it was free from pain, had been growing 
many months, and was still increasing. For the purpose of ascertain- 

* Plate 19, fig. 4. 

f Two cases of osteosarcoma of the thigh bone, by R,. A. Frogley, Esq. Medico- 
Chirurgical Transactions, Vol. xxvi. 
J Dublin Hospital Reports, Vol. iv. 



130 TUMORS OP BONE. 

ing the nature of the tumor, I pierced it with a grooved needle from 
the inside of the mouth. The sensation attendant on the passage of 
the instrument through the tumor assured me that it was composed of 
cartilage, with particles of bone dispersed through it. An ointment, 
containing first iodide of potassium, afterwards iodine alone, was kept 
constantly applied to the cheek, and during its use the tumor slowly 
diminished. At the end of a few weeks, when the patient left the hos- 
pital, about two-thirds of the tumor had disappeared. 

Cartilaginous substance is occasionally combined with other morbid 
products in the tumors of bone. Of such combinations I have met 
with the following instances : — 1. A large tumor surrounding the shaft 
of the tibia, one-half consisting of lobes of cartilaginous substance, with 
an osseous base, its other half consisting of a soft and very vascular 
tissue*. 2. A large tumor occupying the nasal passages, and extend- 
ing through the basis of the cranium to its interior. That portion of 
the tumor which was within the nose consisted of a soft vascular tissue? 
with pieces of cartilaginous substance dispersed through it, whilst that 
portion of it which was within the cranium consisted of lobes of car- 
tilaginous substance with osseous substance in its centref. 3. A large 
tumor surrounding the femur, and apparently originating within it, 
consisting of a mixture of encephaloid and cartilaginous substance, with 
portions of osseous substance dispersed through it J. 

2. OF THE TUMOR OF BONE COMPOSED CHIEFLY OF OSSEOUS SUBSTANCE. 

Of this tumor there are varieties ; one ordinarily denominated Ex- 
ostosis ; the other designated by Muller, who first described it, the 
Osteoid Tumor. 

EXOSTOSIS. 

This tumor occurs mostly in young and middle-aged persons. It is 
recognized by its hardness, freedom from pain, slow growth, the 
healthy condition of the surrounding parts, and the absence of con- 
stitutional derangement. The cellular tissue around the tumor is, 
in most instances, unaltered, but occasionally it is condensed into a 
capsule. 

* Plate 15, fig, 3. t Plate 13, fig. 4, and Plate 17, fig. 3. 

} Museum of St. Bartholomew's Hospital, Pirst series, Nos. 97, 98. 



TUMORS OF BONE. 131 

Exostosis consists of a true bone, with compact and cancellous tis- 
sue, in varying proportions. Its microscopic and its chemical charac- 
ters are the same as those of originally formed bone. But exostoses 
vary in their degree of hardness, and, to some extent, in the relative 
proportions of their ingredients. Dr. Bostock analysed for me an ex- 
ostosis, and reported that it differed from ordinary bone, in containing 
a smaller proportion of animal matter and carbonate of lime, and a 
considerably increased proportion of the phosphate of lime. Valentin 
and Lassaigne have stated, that in some exostoses they found the phos- 
phate of lime to be considerably less than in healthy bone, whilst the 
proportion of carbonate of hme was considerably increased*. It is, 
however, probable, from the observations of Dr. Stark on the propor- 
tions of animal and earthy matters in bone generally!, that the vary- 
ing hardness of exostoses depends less on variations in the proportions' 
of their constituents than on the mode in which they are arranged and 
held together ; in this view, therefore, we are to regard the varieties of 
exostoses, some consisting of cancellous tissue filled by an oily fluid, 
surrounded by compact tissue, others consisting of compact tissue 
throughout, others having the yellowish-white colour, with the smooth- 
ness and compactness of ivory. And Dr. Paget has observed a rela- 
tion in the texture of exostoses with that of the bone whence they 
grow : accordingly that the ivory-like exostosis growing from the hard- 
est bone, its frequent situation is upon the cranium, especially near the 
orbit, into the cavity of which these ivory exostoses often project. 

Most exostoses have cartilage for their base and primordial struc- 
ture. The osseous substance is deposited in the centre of the carti- 
lage, and, as the tumor increases, the layer of cartilage around the 
osseous substance, becoming gradually thinner, ultimately disappears, 
and it may be expected that the growth of the tumor will then cease. . 
It is probable that, in some exostoses, the base and primordial struc- 
ture is fibrous tissue alone. Most of the exostoses I have examined, 
which grew from the last bone of the great toe, appeared to be of this 
kind ; but I have also seen this exostosis surrounded by a thin layer of 
cartilage. And there is a third form of exostosis, without either fibrous 
tissue or cartilage, which is but an outgrowth from, or hypertrophy of, 
a natural process of bone. An exostosis of this kind was removed 
from the front of the tibia, which was evidently but an outgrowth from 

* Beitrage zur Physiologischen und Pathologischen Chemie und Mikroscopie, v. Dr. 
F. Simon. Berlin, 1843. 
t Edinburgh Medical and Surgical Journal, April, 1845. 



132 TUMORS OF BONE. 

its tuberosity, and such has appeared to be the character of the exos- 
toses arising from the processes or ridges of bone, giving insertion to 
tendons. These osseous growths are not apt to increase to a large 
size, and, in consequence, they are less likely to require removal than 
the genuine exostoses having a cartilaginous base. It appears, more- 
over, from the observations of Eokitansky, that the ivory exostosis, 
usually growing from the cranium, is of this kind ; accordingly, that it 
has no cartilage or other primordial structure, and that, at its com- 
mencement, when of the smallest size, it exhibits throughout the same 
hard texture as when it has acquired its maximum growth. 

It appears almost certain, that, during the growth of an exostosis, 
the surface of its attachment to the bone is not in any instance extend- 
ed, and, accordingly, that the increase of the tumor takes place only 
upon its circumference, as might indeed be expected, because here is 
the cartilaginous capsule which is the source of its growth. Practical- 
ly, as it concerns the consideration of the difficulty to be apprehended 
in the removal of the tumor, this point is of much interest ; for, if the 
statement here made be true without exception, we may bo sure that 
the increasing size of an exostosis is not accompanied by an extension 
of its attachment to the bone. 

The question may arise, what is the distinction, if any, between a 
growing exostosis and an ossifying enchondroma ? Both are usually 
noduled on their exterior, and the chemical characters of their constit- 
uents were found to be the same in specimens which Mr. Taylor exam- 
ined for me, both being genuine cartilage, composed of chondrine and 
gelatine in varying proportions ; but in the microscopic characters of 
their cartilages, these differences were noted by Mr. Quekett,- — that, 
in the ossifying enchondroma, there were many separate points of ossi- 
fication, whilst, in the growing exostosis, there was only a centre of os- 
sification, and its cartilage was mixed with fibrous tissue. 

Exostoses vary much in figure. Some are attached to the bone by 
a narrow neck, others by a broad or lengthened base, especially when 
growing from the front of the femur. Occasionally, exostoses are 
movable, either in consequence of the tumor having a narrow cartilag- 
inous neck, or from the neck of the tumor having been broken in the 
movements of the part, the fractured surfaces then become polished, 
and forming a sort of joint. This had occurred in the neck of a mova- 
ble exostosis, which was removed by Mr. Lawrence from the lower and 
inner part of the femur. 

The growth of exostoses is in general irregular. Often they are sta- 



TUMORS OF BONE. 133 

tionary for a considerable period, and then again increase. It cannot 
be determined by the duration or size of an exostosis, whether it con. 
sists chiefly of cartilage or bone. Its growth may have ceased at an 
early period, when its cartilage had wholly disappeared, and then, al 
though of small size, it would consist wholly of bone. The ivory exos- 
tosis growing from the skull rarely becomes larger than a marble ; but 
elsewhere it has grown to a large size. When it has exceeded its usual 
size upon the skull, it has generally become thick and round at its base, 
and tapering to a point, thus acquiring a horn-like form. There is, 
however, in the anatomical museum of the University of Cambridge,, 
an example of a large ivory exostosis, filling the nasal and orbitar cavi- 
ties, and projecting on the outside and in the interior of the skull, 
which appears to have commenced either in the diploe of the cranial 
bones or in their inner table, their outer table being expanded over part 
of the tumor. 

Exostoses, in some instances, appear to be the consequence of vio- 
lence to the part. A man in St. Bartholomew's Hospital had a large 
exostosis growing from the lower and inner part of the femur ; and he 
stated that he had been kicked by a horse in that situation shortly be~ 
fore the tumor commenced. 

Instances are not infrequent of more than one exostosis growing 
from a bone ; also of many exostoses growing from various bones in the 
same individual. There are also instances of exostoses occurring in 
several members of the same family ; also in children, one of whose pa- 
rents were similarly affected. 

The diagnosis of exostosis is an important part of its history. The 
hardness of the tumor, its slow growth, freedom from pain, and the ab- 
sence of constitutional derangement, are its ordinary characters. If 
the tumor is painful, if it is soft at one or more points, if its growth has 
been rapid, or if the health is deranged — in any of these circumstances 
there would be reason for suspecting the tumor not to consist simply of 
osseous substance. 

An exostosis growing from the bone of a finger or toe, may be, with 
difficulty, distinguishable from the tumor resulting from expansion of 
the wails of the bone around a morbid deposit within it. This difficul- 
ty occurred to Dupuytren, in a case where there were two tumors, one 
the size of a hen's egg, which had been nine years growing upon the 
second phalanx of the forefinger ; the other, of more recent date, the 
size of a hazel-nut, growing upon the metacarpal bone of the same fin- 
ger. Dupuytren observed, that if the tumors were simple exostoses, 

12 



134 TUMORS OF BONE. 

amputation of the finger, upon which the larger tumor had formed, 
would be sufficient ; and that the smaller tumor of the metacarpal bone, 
at present causing little inconvenience, would probably be stationary. 
In this view he removed only the finger. But the tumor upon it prov- 
ed not to be a simple exostosis ; it consisted of the walls of the bone 
expanded around a fatty substance, deposited within it*. 

An exostosis may be inconvenient, simply by its magnitude ; but in 
general it is so, by interfering with the adjacent nerves, blood-vessels, 
or other parts. In the instance of an exostosis growing from the lower 
and inner part of the humerus, severe pain was felt along the forearm 
and hand, in the direction of the ulnar nerve ; and in another case, I 
found, on dissection, the ulnar nerve split into two branches by a small 
exostosis, which penetrated it. A man in St. Bartholomew's Hospital 
had an exostosis growing from the posterior surface of the clavicle. 
He suffered no inconvenience from it whilst the arm was a! rest, but di- 
rectly it was moved he suffered acute pain in the direction of the axil- 
lary plexus of nerves, and its branches. Mr. Mayo showed me a par 
tient in the Middlesex Hospital, in whom an aneurism was supposed to 
have arisen from the subclavian artery ; but, upon more careful exami- 
nation, an exostosis was discovered growing from the first rib, pushing 
the artery forwards and flattening it. Upon the front of the swelling, 
the pulsation was strong and extended over a large space ; but at its 
sides no pulsation could be felt. The pulsation of the artery in the 
axilla was feeble. In the brachial, radial, and ulnar arteries, no pulsa- 
tion could be felt. Sir Astley Cooper has recorded a case in which an 
exostosis growing from the lower cervical vertebra, and extending to- 
wards the clavicle, compressed the subclavian artery. The pulse at 
the wrist was in consequence stopped, and gangrenous spots appeared 

in the armf. 

Other organs may be affected by their contiguity to exostoses. An- 
dral has related a case wherein difficulty of deglutition was experienc- 
ed from compression of the oesophagus, by an exostosis growing from 
the body of a vertebra^. And there is an instance recorded by Dr. 
Eeid, in which a conical exostosis, growing from the posterior part of 
the odontoid process of the second cervical vertebra caused fatal com- 
pression and softening of the spinal cord§. 

# Journal Universel et Hebdamodaire, Decembre, 1833. Compte rends de la clin- 
ique chirurgicale de l'Hotel Dieu. 

t Surgical Essays, p. 173. 

J Pathological Anatomy, Transl Vol. ii. p. 278. 

§ London and Edinburgh Journal of Medical Science, March, 1843. 



TUMORS OF BONE. 135 

An exostosis growing from the inner table of the skull, has been the 
immediately exciting cause of epilepsy. In a boy, admitted into St. 
Thomas's Hospital on account of epileptic fits, a spot of the skull was 
discovered where pressure gave much uneasiness. Here the trephine 
was applied. At the instant of raising the circle of bone, he had a 
sharp epileptic fit ; but this was the last. From the imier table of the 
portion of bone removed, a spiculum, a quarter of an inch long, pro- 
jected, pressing upon the dura mater*. In a case recorded by Boyer, 
an exostosis growing from the os pubis and compressing the neck of the 
bladder, caused retention of urine, for the relief of which a catheter 
could not be introduced! . M. Jules Cloquet, in examining the body 
of an aged female, found the symphisis pubis ossified, and a bony 
growth projecting from its posterior surface into the cavity of the blad- 
der. The pressure of the tumor had caused the absorption of the coats 
of the bladder : hence, on opening its cavity, the bony tumor was seen 
projecting into it, covered only by a thin layer of fibro-cellular tissue, 
which, at the base of the tumor, was continuous with the mucous mem- 
brane of the bladder J. 

The growth of an exostosis from the bone of a toe requires particular 
notice, on account of the inconvenience it usually occasions§. It is 
rarely found upon any other than the great toe ; and it generally grows 
from the upper surface, margin, or extremity of the last phalanx, rais- 
ing the nail and projecting from beneath it. In some instances, the 
exostosis has begun to grow shortly after the toe has been struck 
against a stone or other resisting body ; in others, it has been thought 
to be owing to the pressure of a tight boot. In some cases, the exos- 
tosis is attached to the bone by a narrow neck, and in others by a broad 
base. Pain and lameness are the usual consequences of the displace- 
ment of the nail, by the increase of the tumor beneath it. The exosto- 
sis has been, in some instances, mistaken for a warty excrescence grow- 
ing from the soft parts ; and in others, for the ordinary fungous ex- 
crescence springing from beneath the nail. A patient in St. Bartholo- 
mew's Hospital had a small red fleshy tumor projecting from the end of 
the great toe, which was preceded by an abscess beneath the nail. 
The toe was amputated, and the tumor found to consist of fibrous tis- 
sue, with an osseous base attached to the last phalanx. 

* Further Enquiry concerning Constitutional Irritation, by B. Travers, p. 285. 
t Memoires de l'Academie de Dijon. 
J Pathologie Chirurgicale, Plate ix. fig. 7. 

§ The first distinct notice of this exostosis is in a paper, by Mr. Liston, in the 26th 
volume of the Edinburgh Medical and Surgical Journal. 



136 TUMORS OF BONE. 

In the treatment of exostosis we have to consider, first, the means 
of arresting its growth, and secondly, the question of removing it by 
operation. Very little reliance can be placed on depletory remedies in 
stopping the growth of an exostosis. There are, however, instances of 
exostoses accompanied by turgescence of the surrounding veins, and 
even by enlargement with pulsation in the adjacent arteries, and in- 
creased heat in the parts. Under these circumstances, the persevering 
use of leeches and evaporating lotions might be serviceable. There 
have also been cases in which counter-irritation established close to an 
exostosis has appeared to be of service. A boy, under the care of Mr. 
Abernethy, in St. Bartholomew's Hospital, had an exostosis growing 
from the middle of the humerus ; it was painful and increasing. An 
issue was made at the base of the tumor, and as soon as the discharge 
from it was established, the exostosis became free from pain, and ceas- 
ed to grow. But, in other cases, I have directed the application of 
issues close to exostoses without influencing their growth. I have seen 
instances in which the application of iodine and mercury to an exosto- 
sis was followed by the diminution of it ; and cases are recorded in 
which friction and compression of the tumor have had the same effect. 
In the instances of success from such measures, it is probable that the 
tumors consisted chiefly of cartilage, for, upon the osseous tissue, it is 
not likely that they would have any effect. 

An exostosis being a growth from sound bone, and, in general, a 
strictly local malady, its removal by operation may be undertaken, with 
the expectation that it will not be reproduced. I have known nume- 
rous instances in which the removal of the tumor was not followed by 
any reproduction of it ; and I have seen a few instances in which the 
exostosis was reproduced at the same spot, in consequence, it was 
thought, of the tumor not having been completely removed. 

It may be stated, that absolute security against the reproduction of 
an exostosis can be obtained only by the removal of every part of its cir- 
cumference. If but the smallest portion of the exterior of the exosto- 
sis with its cartilaginous capsule be left, reproduction of the tumor will 
be, at the least, not an improbable occurrence. 

When an exostosis becomes inconvenient, from its size and interfer- 
ence with the contiguous parts, the patient is likely to solicit its remov- 
al. The propriety of undertaking the operation will, of course, depend 
on the size and connexions of the tumor ; and, in deciding the ques- 
tion, it is to be recollected that exostoses often cease to grow before 
they have acquired such a size as to be materially inconvenient. The 



TUMORS OF BONE. 137 

growth of the tumor may stop whilst it is still small, and, in conse- 
quence, no operation be required. 

In removing an exostosis, the first step is to denude it to its base ; 
and, usually, this is easily effected, as the cellular capsule of the tumor 
is but loosely adherent to it. The next step is to detach the tumor 
from the bone. For this part of the operation, strong knives, cutting 
forceps, and saws of various shapes, must be provided, for until the 
base of the tumor is exposed, and its form recognized, it will be uncer- 
tain with what instrument the division of it can be best effected. . When 
an exostosis is covered by muscle, the fibres should be cut transverse- 
ly, because the retraction of them will facilitate the exposure of the tu- 
mor ; also, because suppuration is almost sure to occur at the bottom of 
the wound, and the retraction of the cut edges of the muscle will faci- 
litate the discharge of the matter, and prevent the evil of its burrow- 
ing among the surrounding parts. 

After the removal of an exostosis, especially when deep-seated, it is 
not expedient to approximate the divided edges of the integument, in 
the view of obtaining their adhesion ; since, in the exposure and re- 
moval of the tumor, so much injury is usually done to the surrounding 
cellular tissue, that suppuration through it will almost certainly ensue. 
The wound should be simply covered with folded damp linen ; and, by 
this means, the healing of it will be completed in a shorter time than if 
the adhesion of its sides had been in the first instance attempted. 

When, from the situation of an exostosis, the complete removal of it 
by the saw, or other cutting instrument, cannot be effected, the potassa 
fusa or nitric acid may be applied to the remaining portion of the tu- 
mor, in order to produce its exfoliation, and the same measure may be 
adopted, if the surface of the bone, from which an exostosis has been 
removed, should be discovered to be unsound. And there have been 
instances in which the complete removal of an ivory exostosis from the 
cranium being found impracticable, on account of its extreme hardness, 
the application of potassa fusa to the remaining part of the tumor was 
followed by the separation of it. 

In the instances of exostosis growing from the last bone of a toe, the 
propriety of interfering with it will depend on the amount of pain and 
lameness it occasions. I have seen cases where it occasioned no in- 
convenience ; usually, however, it causes so much pain that the patient 
solicits its removal. It has been a question, whether only the tumor 
should be removed, or the bone whence it has arisen, be amputated. 

Experience has appeared to be in favour of the latter measure ; for in 

12* 



138 TUMORS OF BONE. 

some of the cases, where the tumor alone had been removed, it is 
stated to have been reproduced. When the exostosis arises from the 
last bone of the great toe, the amputation should be performed through 
the articulation of the first with the second phalanx ; but when it 
grows from the last bone of any of the other toes, the amputation should 
be performed between the bones of the first and second, rather than 
between the second and third phalanx, on account of the small size of 
the latter. 

Hitherto the objection to removing, with the exostosis, only the por- 
tion of the phalanx from which it grows, has been the severity of the 
•pain attendant on the division of the sensitive structures beneath the 
root of the nail ; but with the use of chloroform or aether, this objec- 
tion being removed, the mode of operating in these cases successfully 
•adopted at St. Bartholomew's Hospital has been as follows : first, to 
soften the nail by enveloping the toe for twenty-four hours in a poul- 
tice, then, to pass a scalpel from the end of the toe, close upon the 
.under surface of the phalanx, almost to its base — a flap of the soft 
parts will thus be formed ; next, the knife is to be passed, just beyond 
the exostosis, across the softened nail and through the subjacent tissue 
to the bone ; and, lastly, by the cutting forceps, the phalanx is to be 
divided transversely, near its base. The flap of skin being brought 
over the wound, and confined there by a couple of stitches, will readily 
unite to the subjacent parts. The advantages of the foregoing pro- 
ceeding are, that it does not interfere with either the flexor tendon or 
the last joint of the toe ; and that it leaves the bulbous end of the toe 
uninjured ; in fact, it leaves the toe not otherwise altered than by a 
little shortening of it. 

When an exostosis arises from the femur, close to the knee-joint, it 
may be difficult to decide whether its removal can be effected without 
opening the joint. The following case of this kind occurred in St. 
Bartholomew's Hospital. A man, aged twenty-five, had an exostosis 
growing from the lower and front part of the femur, which commenced 
.five years previously. The tumor, increasing, had of late interfered 
with the knee-joint, occasioning pain in it, and distension of the syno- 
vial membrane by fluid. The tumor was oblong, the long diameter of 
its base being in the axis of the femur, and measuring about four inch- 
es, the breadth of its base about two inches. The increase of the tu- 
mor, in such a direction that it projected into the knee-joint, induced 
the man to solicit its removal. Its connexions were carefully exam- 
ined, with reference to the question of its being possible to remove it, 



TUMORS OF BONE. 139 

without injuring the joint ; and it was decided that the operation might 
be safely undertaken. 

An incision was made through the rectus and crurgeus muscles to 
the base of the tumor, on the side most remote from the knee-joint. 
But in doing this, though with all possible caution, the joint was open- 
ed, and it was now discovered that the synovial membrane, in yielding 
to the accumulation of fluid in the joint, had extended upwards upon 
the tumor, and some way beyond it upon the front of the femur. 
With much difficulty, on account of the deep situation of the tumor, 
the breadth of its base, and the hardness of its texture, I effected its • 
removal by means of a chisel and cutting forceps. The inflammatory 
fever, immediately consequent on the operation, was not severe ; but 
as this subsided, there was no return to health. Constitutional de- 
rangement of another kind ensued ; its prominent features were rigors, 
collapse, pain in the head, cramps in the limbs, and extreme prostration 
of nervous power ; and it soon became evident, that suppuration had 
taken place through the subcutaneous cellular tissue of the whole limb, 
from the hip to the foot. At the end of the third week from the op- 
eration, the patient died. 

On examining the limb, a large suppurating cavity was found in the 
lower part of the thigh communicating with the knee-joint, the syno- 
vial membrane and cartilages of which were in great part destroyed. 
There was, however, a sufficient portion of the synovial membrane left 
to show, that it had extended upwards upon the front of the femur 
to the extent of five inches above the articular cartilage, and conse- 
quently much beyond the limits of the exostosis*. 

In this case, an incorrect view was taken of the disposition of the 
synovial membrane with respect to the exostosis, and consequently the 
danger of opening the knee-joint was not rightly estimated. But this 
error of diagnosis admits of the following explanation. When the man 
was admitted into the hospital, there was a large accumulation of fluid 
within the knee-joint, which, under the influence of rest, leeches, and 
cold lotions, wholly disappeared ; but the synovial membrane did not 
contract to its former dimensions. We expected that it had done so, 
and accordingly that the operation might be undertaken, without risk 

* This tumor was apparently of the character of an outgrowth, or hypertrophy of 
bone, for it consisted of cancellous texture, which, at the base of the tumor, was contin- 
uous with the cancellous texture of the femur, Eepresentation of the portion of the 
femur from which the tumor was removed, Plate 14, fig. 2. 



140 TUMORS OF BONE. 

of injuring the joint. Subsequently, in the hospital, I removed an 
increasing exostosis from the lower and inner part of the femur ; but 
here there had been no accumulation of fluid within the knee-joint, and 
consequently no extension of the synovial membrane beyond its natural 
limits. 

When proceeding to remove exostoses, it is well to bear in mind, 
that in certain situations they are in general very hard, and in conse- 
quence not easily divided. An exostosis growing from the lower jaw 
will probably be dense, from its relation to the texture of the bone 
whence it grows. But the exostoses growing from the skull, includ- 
ing those which project into the orbit, have been found of so hard a 
texture that they could not be divided, either with the saw or cutting 
forceps. 

Boyer alludes to two instances of exostosis, in which the tumor 
spontaneously separated from its connexions*. Another case has been 
recorded by Mr. Hilton, in which a large ivory exostosis spontaneously 
separated from the bones of the face. The loosening of the tumor 
commenced several years before its separation was completed, and the 
process of separation was not accompanied by pain or haemorrhage. 
The tumor weighed fourteen ounces. Healthy granulations arose 
from the parts with which it had been connected! . It is doubtful 
whether, in these instances, the osseous tumor was actually a growth 
from bone. More probably, it was formed in the cellular tissue, and, 
by suppuration in the parts around, became gradually detached from 
its connexions. In a case which occurred in St. Bartholomew's Hos- 
pital, suppuration appeared to have taken place in the centre of a large 
exostosis. The tumor was attached to the head of the tibia ; it con- 
sisted of a solid mass of bone, with a suppurating cavity in its centre. 
From this cavity, an ulcerated passage extended through the thick os- 
seous substance forming the walls of the tumor, and through the in- 
vesting soft parts, to the outside of the limbf . 

OSTEOID TUMOR. 

More than general observation had not been directed to the varieties 
of osseous tumors, when the description of one of these, not before 
noticed, was published by Muller, under the designation of the osteoid 

* Traite des maladies chirurgicales, Tome iii. p. 554. 
t Guy's Hospital Reports, September, 1836. 
$ Plate 12 3 fig. 1. 



TUMORS OF BONE. 141 

tumor*. But the more appropriate designation of this disease is the 
Malignant Osseous Tumor, as marking the prominent feature which 
distinguishes it from the innocent osseous tumor, or exostosis. 

I have had the opportunity of seeing three instances of this disease. 
In two of them, it surrounded the lower part of the femur ; and in the 
third, the upper part of the tibia. The disease occurred in individuals 
between the ages of thirty and forty-five. One case had been eighteen 
years in progress ; and in the two others, it could not be ascertained 
that the disease had existed more than a few months. 

In all the cases, the tumor of the bone was accompanied by similar 
morbid deposits in the adjacent and in distant absorbent glands, con- 
verting them into chains of osseous tumors ; and in two of the cases, 
there was an additional feature of malignancy in the combination of the 
primary tumor of bone with similar growths in distant organs and 
tissues. In each case, the disease originated within the bone, and ac- 
cordingly the tumor around it was accompanied by similar growths 
within its medullary tube and cancellous texture. 

The osseous substance in these tumors is either of a yellow colour 
and ivory-like texture, or it consists of a dull white, chalk-like sub- 
stance, which can be scraped or rubbed into a powder. The osseous 
substance is united to a soft tissue, which usually constitutes the exte- 
rior of the tumor, and besides fills the interstices in its harder constit- 
uent. The soft tissue is of a greyish- white colour, and, when examined 
by the microscope, is found to be fibrous. But in some instances, the 
soft tissue of these tumors has closely resembled the firmer sort of 
encephaloid deposit. It was so in one case, where the osseous tumor 
of the tibia was combined with growths apparently of an encephaloid 
nature in distant parts of the bodyf. 

There is clear evidence of the malignancy of this tumor of bone, and 
accordingly we shall desire to know its characters in the early stage 
of the disease, in order that the amputation of the limb in which the 
disease is situated may be performed whilst the absorbent glands adja- 
cent to it are uncontaminated. Difficulty will be experienced in the 
diagnosis ; still, however, there are characteristic features of this tu" 
mor, which it may be well here to recapitulate. They are — 

* Ueber ossificirende Schwamme oder Osteoid Geschwiilste, von Joh. Miiller, Arcliiv 
fiir Anatomie, &c. 1843. 

t In this instance, however, the morbid substance was not examined by the micro- 
scope. In all the instances where this was done by by Mr. Paget, he found the soft con- 
stituent of these tumors to be distinctly fibrous. 



142 TUMORS OP BONE. 

First, The tendency to its growth around the lower part of the fe- 
mur, just above its condyle, and around the upper part of the tibia, 
just below its head. 

Secondly, The tendency of the tumor to assume an oblong, 
rather than the globular, form which belongs to many other tumors of 
bone. 

Thirdly, The absorbent glands, when contaminated in this disease, 
assume the form of hard, isolated, and movable tumors. 

This tumor closely surrounds the bone from which it grows, and con- 
sequently it is immovable. In this particular, however, and in the 
firmness of its feel, it does but resemble many of the fibrous tumors of 
bone, from which, therefore, its distinction may not be easily estab- 
lished. 

In illustration of the foregoing history of the osteoid tumor, the fol- 
lowing instances of it are related. 

1. Malignant Osseous Tumor of the Tibia. A woman, thirty 
years of age, was admitted into St. Bartholomew's Hospital, with a 
hard and immovable tumor, occupying the upper half of the leg ; and 
in the popliteal space there were two smaller, hard, but movable tu- 
mors. The large tumor had been eighteen years in progress, and the 
small tumors were of recent formation. The malignant character of 
the disease was indicated by sallowness of countenance and collapse of 
the features. The limb was amputated through the lower third of the 
thigh. The large tumor was found to consist almost wholly of bone, 
which, in one part, presented the yellow colour and density of ivory, 
and hi another was cancellous. The ivory-like portion of the tumor 
was continuous with the same kind of deposit within the medullary tube 
of the tibia. The walls of the tibia were yellow, and of ivory-like 
density. The exterior of the tumor was composed of soft substance, 
which, in some parts, was fibrous, and in others, encephaloid. The 
smaller tumors in the ham were composed of osseous substance, partly 
ivory-like, and partly cancellous ; and it appeared probable that they 
were formed by ossification of the absorbent glands. Within the me- 
dullary tube and cancellous texture of the femur, there were deposits 
of ivory-like bone, and of soft substance, in some parts fibrous, in oth- 
ers encephaloid. 

The stump healed soundly. Cough and difficulty of breathing en- 
sued, and continued to the death of the patient, two months after the 
removal of the limb. 

Numerous isolated ivory-like deposits, mixed with fibrous and ence- 



TUMORS OF RONE. 143 

phaloid substance, were found within the medullary tube of the remain- 
ing portion of the femur. The femoral, iliac, and cervical absorbent 
glands were converted into fibrous and encephaloicl substance, with os- 
seous deposits in its centre. Many encephaloid growths were found in 
the pleura, pericardium, and lungs ; and there was a large mass of the 
same substance deposited around and within the coats of the vena cava 
superior*. 

The fact will here be observed of morbid growths occurring simulta- 
neously in two bones of a limb. In the tibia, these growths were ac- 
companied by tumor ; in the femur they were not : here, consequently, 
there was no sign of their existence. 

2. Malignant Osseous Tumor of the Femur. A man, aged thirty, 
was admitted into St. Bartholomew's Hospital, under the care of Mr. 
Lawrence, with a swollen and painful state of the right knee-joint, con- 
sequent on a fall, for the removal of which, antiphlogistic treatment 
was successfully employed ; but shortly afterwards, a painful swelling 
arose immediately above the knee, and gradually extended around the 
lower third of the thigh. A softening of the swelling at one part be- 
ing discovered, an incision was made into it, from which, arterial blood 
freely flowed. Pulsation was now discovered in the swelling ; and at 
the same time it was observed, that the leg had become cedematous, 
and that the toes were colder than in the opposite limb. The femoral 
artery was then tied. Pulsation in the tumor ceased, and its size gra- 
dually diminished ; but after some time it again enlarged, sloughing of 
the skin and central substance of the tumor ensued, but unaccompanied 
by haemorrhage. The man gradually sank from exhaustion. 

On examining the limb, I found the tumor to consist of a compound 
of soft fibrous and dense osseous substance, the latter extending com- 
pletely around the femur. The whole series of femoral, inguinal, and 
lumbar absorbent glands were converted into osseous tumors. The fe- 
moral and popliteal vessels were sound. 

In this case, the tumor of the femur and the tumors of the absorb- 
ent glands were identical in structure, both being composed almost 
wholly of a solid, dull white, chalk-like osseous substance, which, in the 
femur, was continuous with a similar deposit in the medullary and can- 

* Representations of some of the specimens from the above case, Plate 19, figs. 
1, 2, 3. 



144 TUMORS OF BONE. 

cellous tissue of all that part of the bone which was surrounded by the 
tumor*. 

3. Malignant Osseous Tumor of the Femur. I admitted into the 
hospital a man, aged forty-five, having a solid tumor closely surround- 
ing the lower third of the femur. He stated that it had been growing 
not more than four months ; but probably, it was only within this peri- 
od that his attention had been directed to the tumor, on-account of its 
being painful. His countenance was sallow and his features shrunk. 
In the groin, especially above Poupart's ligament, there were several 
hard, movable, and not painful tumors. The tumor of the thigh was 
oblong, immovable, and so firm that it seemed to be composed chiefly 
of osseous substance. The disease was considered to be malignant, 
and accordingly the removal of the limb seemed justifiable only on the 
ground of the man desiring to take the chance of his life being pro- 
longed by the operation, when made acquainted with the circumstances 
of his case. He left the hospital, and in a month afterwards returned 
to it, when the tumor had extended up the thigh to its middle. He 
now, although dissuaded from the operation, yet so strongly urged its 
performance, on account of the severe pain in the tumor, that I yield- 
ed to his solicitations, and amputated the thigh in its upper third. 

On examining the tumor, I found it to consist of osseous substance 
and of fibrous tissue. The osseous substance was yellow, and of ivory- 
like texture .; it formed the deeper part of the tumor, and was continu- 
ous with masses of ivory-like osseous substance, which nearly filled the 
medullary tube of the femur to the extent of the tumor surrounding it. 
The fibrous substance, constituting the exterior of the tumor, extended 
into the spaces intervening between irregular portions of the osseous 
substance. In the muscles, and in the cellular tissue adjacent to the 
tumor, there were many circumscribed deposits, varying in size 
from that of a pea to that of a hazel-nut, composed wholly of fibrous 
tissue. 

The man did not survive the operation more than two months. The 
wound of the amputation had nearly healed, but there was a large ab- 
scess deep in the thigh, in the direction of the psoas and iliacus mus- 
cles, and communicating with the hip-joint, through the bursa under- 
neath the psoas. The articular cartilage of the hip-joint was in great 
part destroyed. The tumors in the groin, occupying the line of the 

* Museum of St. Bartholomew's Hospital, First series, Nos 108, 109, 110. With ref- 
erence to the remarkaLIe occurrence of pulsation in this tumor, the case will be again 
noticed in the section on the Tumors of bone which pulsate. 



TUMORS OF BONE. 145 

inguinal and lumbar absorbent glands, consisted of fibrous tissue, with 
osseous deposits in the centre of some of them. Numerous tumors, 
presenting the same characters as those in the groin and abdomen, were 
dispersed through the lungs, immediately beneath the pleura. Within 
the medullary tube of the small portion of the femur which had been 
left, and at some distance from its amputated extremity, there was a 
circumscribed fibrous growth of the same character as that which was 
the chief constituent of the other tumors. 

In this case, it will be observed, there were isolated morbid growths 
within different parts of the femur, in addition to the similar morbid 
deposits in adjacent and distant absorbent glands, and in the lungs. It 
should also be noticed, that the disease existed in only one bone ; other 
bones were examined, but they were found healthy. 

3. TUMOR OF BONE, COMPOSED CHIEFLY OF BRAIN-LIKE, OR ENCE- 
PHALOID SUB STANCE — CARCINOMA MEDULLARE — FUNGUS MEDULLA- 
RS (muller). 

This tumor is of frequent occurrence ; it is usually a primary dis- 
ease, originating within the bone, and occurring in general before the 
age of forty, but occasionally at a later period. Its growth is, in some 
instances, rapid, attended with severe pain and wasting of the body; 
whilst in others it is slow, with but little pain, or disturbance of the 
health ; thus, in some cases, it has been a disease of only a few months' 
growth, whilst in others, it has been several years in progress. The 
disease, in its advance through the bone, is, in most instances, accom- 
panied by absorption of the walls, but occasionally by the expansion of 
them into a cyst enclosing the encephaloid substance. In some rare 
instances, the expansion of the walls of the bone has been accompanied 
by increase of their thickness, giving to the tumor the characters of a 
solid mass of bone*. More commonly, the expanded walls of the bone 
are partially absorbed, and the tumor is in consequence firm and re- 
sisting in some parts, soft and elastic in others. The softness and elas- 
ticity of the tumor have often induced the belief that it contained fluid, 
and accordingly it has been punctured with the effect of discharging 
blood freely from it, but without diminution of its bulk. Often it hap- 
pened, that when the encephaloid disease had in part penetrated the 
walls of the bone, the remaining portion of them suddenly gave way, 

* Museum of St Bartholomew's Hospital, First series, Nos. 159, 160. 

13 



146 TUMORS OF BONE. 

in the manner of a spontaneous fracture, after which the limb rapidly 
enlarged, from the accumulation of encephaloid substance around the 
bone ; and the pain, which was before severe, almost wholly subsided, 
apparently because the morbid deposit was no longer confined within 
the walls of the bone or its periosteum. 

The encephaloid tumor of bone occasionally attains a very large size, 
the extent of the morbid deposit being apparently limited only by the 
degree to which the skin covering it will yield ; and in some instances 
it has been diffused through the entire limb, occasioning enlargement 
of the arm, thigh, or leg, to such a degree that, in its circumference, 
it has equalled the body of the patient. When at length the skin cov- 
ering the tumor inflames, it usually ulcerates at one or more points, 
and the openings give issue to blood, or to a soft bleeding fungus. In 
some cases, suppuration occurs through the coverings of the tumor, 
followed by the profuse discharge of a fetid fluid, consisting of a mix- 
ture of pus, encephaloid substance, and blood. 

The absorbent glands contiguous to the encephaloid tumor of bone 
are in general not readily affected. I have seen instances of this tu- 
mor of enormous size in the thigh, without any change in the inguinal 
glands. 

The encephaloid tumor frequently originates in the cancellous tex. 
ture of the condyles and adjacent part of the shaft of the femur, or in 
the cancellous texture of the head of the tibia ; and in either situation, 
it is liable to be mistaken for ordinary disease of the knee-joint. The 
commencing symptoms of the encephaloid disease have been, in some 
of these cases, exactly the pain, stiffness, and slight swelling of the 
joint which usually accompany inflammation of the synovial membrane ; 
and at a more advanced stage, the soft, elastic, encephaloid tumor, oc- 
cupying the whole circumference of the joint, has been mistaken for 
the swelling of it, consequent on thickening of the synovial membrane. 
Even in instances where the encephaloid tumor has acquired a large 
size, its nature has not been suspected, and consequently amputation of 
the thigh has been performed in the belief that the case was one of or- 
dinary disease in the knee-joint. In an instance, moreover, of ence- 
phaloid disease originating within the patella, it presented the ordinary 
characters of the bursal tumor upon the knee, and the removal of the 
tumor was undertaken, when it was found to consist of encephaloid 
substance and fibrin, enclosed in a cartilaginous shell*. The difficulty 

* Observations pour servir a, Fhistoire du cancer des os. Par le Professenr Dubreuil, 
Hebdomadaire de Medecine, Juin, 1835. 



TUMORS OF BONE. 147 

of the diagnosis may lie in the opposite direction. There are instances 
of suppuration around the knee-joint which present many of the fea- 
tures of encephaloid disease. A case of this kind, which I saw, oc- 
curred in a child seven years old. Without apparent cause, a large 
swelling had, in the course of a few months, formed around the front 
and sides of the knee-joint ; it was every where soft and elastic, but 
without the feel of fluctuation on pressure ; and the veins ramifying 
upon it were large and tortuous. It was for some time uncertain whe- 
ther this was an instance of encephaloid disease, or of simple abscess ; 
it proved to be the latter ; but the suppuration was deep, between the 
muscles and synovial membrane of the knee-joint, and it was to this 
circumstance that the indistinctness in the characters of the disease 
appeared to be owing. 

The encephaloid tumor of bone consists of the peculiar morbid depo- 
sit implied by its name, in all the varieties of colour and consistence 
belonging to this deposit in other organs ; it is, therefore, in different 
instances, white, yellowish, or grey, or dark red, from the mixture of 
blood with it. Its consistence varies much : in some instances it is as 
soft and compressible as foetal brain ; and in others, it presents the 
firmness, with the elasticity, of fresh adult brain. Often the encepha- 
loid substance is mixed with other morbid products : thus, part of the 
tumor is occasionally composed of a dark-brown soft substance, not en- 
cephaloid in its characters, with cavities in it filled by serous or gelati- 
nous fluid, or with blood. In some instances, so large is the propor- 
tion of serous or sanguineous fluid mixed with the encephaloid sub- 
stance, that the enlarged limb in which the disease is seated, appears 
to consist of nothing else than a bag of fluid. Osseous specks and 
fibres are often mixed with the encephaloid substance, the osseous mat- 
ter being, in some instances, apparently, a new deposit, and in others 
the remains of the original fabric of the bone. In some cases, the os- 
seous substance forms the base of the tumor ; and in others, it is dis- 
posed in the form of a network, extending through the tumor, the in- 
terstices of which are filled with encephaloid substance. 

In two instances of limbs amputated on account of encephaloid dis- 
ease originating in the condyles of the femur, I found the unsoundness 
of the bone continued through its shaft to the amputated extremity—-' 
also a similar unsoundness of the tibia — each bone presenting through- 
out an enchymosed appearance in its compact tissue. From these 
facts we learn that the encephaloid tumor is, in some instances, com- 
bined with unsoundness of the vascular structure of the bone, and that, 



148 TUMORS OF BONE. 

although the tumor may be confined to a portion of the bone, the un- 
soundness of vascular structure may extend through the whole of it. 
Fur ther, the practical conclusion from the foregoing would appear to 
be, that after amputating a limb on account of encephaloid disease ori- 
ginating in the bone, if the bone were divided, the reproduction of en- 
cephaloid disease would probably ensue from its remaining portion. 
But in the two cases just mentioned, this did not happen ; in each, the 
stump healed soundly, and there was no return of disease. Still, the 
ascertained fact of the encephaloid tumor being occasionally combined 
with unsoundness of the bone to an indefinite extent, is sufficient to 
warrant the rule, that, in such cases, the amputation should, if possi- 
ble, be performed, not through the bone in which the disease originat- 
ed, but either through the contiguous joint, or above it ; that when, for 
example, encephaloid disease has originated in the radius or ulna, am- 
putation should be performed through the elbow-joint, or above it ; that 
when the disease has originated in the humerus, amputation should be 
performed at the shoulder-joint ; and that in the instances of this dis- 
ease occurring in the lower end of the tibia, amputation should be per- 
formed above the knee-joint. 

The diagnosis of the encephaloid tumors of bone may be obscured 
by the circumstances of its commencement ; thus it is, in many in- 
stances, directly preceded by local injury happening to a person in per- 
fect health, and followed by slight inflammation in the part, upon the 
subsidence of which the malignant disease is gradually developed. The 
following is a remarkable instance of this. 

Encephaloid Tumor following Injury of the Knee. A boy, aged ten 
years, was admitted into St. Bartholomew's Hospital, having four days 
previously fallen upon his knee ; since which, the joint had been stiff and 
painful. From the examination of the limb it was concluded that there 
was either a fracture of the femur just above the condyles, or a sepa- 
ration of the epiphysis. The limb was confined in splints. A swel- 
ling of the soft parts around the knee-joint gradually arose, accompani- 
ed with heat and tenderness in the skin covering it. The swelling be- 
came so soft that it was supposed matter had formed in it ; according- 
ingly it was punctured, but only blood issued from the opening. The 
swelling gradually extended up the thigh, enlarging it to the dimen- 
sions of the thigh of an adult, but the absorbent glands in the groin 
were unaffected. At length the skin gave way towards the ham, and 
an ulcerated passage into the tumor here formed, from which foetid 
matter was profusely discharged. Four months after the commence- 



TUMORS OF BONE. 149 

merit of the disease, the boy died. On examining the thigh, eneepha- 
loid substance was found extensively diffused through the cellular tis- 
sue between the muscles and the bone. The shaft of the femur was 
separated from the condyles, and the unsoundness of the bone at this 
part indicated that the disease had commenced within it. 

It is to be recollected that the encephaloid tumor of bone is, in one 
case, of slow, and, in another, of rapid growth ; in one case attended 
with pain and disturbance of the health, and in another with neither of 
these symptoms ; that in one case the coverings of the tumor feel soft 
throughout, in another firm in the situations where osseous substance 
enters into its composition : moreover, that the encephaloid matter has 
been found enclosed in an osseous cyst, which, in one case, was thin 
and crepitating, and, in another, so thick as to give to the tumor the 
solidity of an exostosis. Surrounded by this great variety of features, 
it is difficult to establish for the encephaloid tumor any well-marked 
ground of diagnosis from other tumors growing from bone or perioste- 
um, or appearing to do so by their situation and attachments. 

It may in some degree aid the diagnosis of the encephaloid tumor of 
bone, when situated close to the knee-joint, if the fact be noted, that an 
encephaloid tumor in this region, will almost certainly have originated 
either in the condyles of the femur, or hi the head of the tibia. To 
this I know but a single exception, in the instance of an encephaloid 
tumor filling the ham, and thence advancing upon the sides of the knee ; 
for here the disease appeared to have originated in the cellular tissue 
of the popliteal space : certainly it had no connexion with the adjacent 
bones, which were sound*. 

The question of amputating a limb, which is the seat of the ence- 
phaloid tumor of bone, must chiefly rest on the evidence to be obtained 
of the probability, or otherwise, of similar disease being reproduced 
either in the remaining part of the hmb or elsewhere. The following 
facts bear upon this point. A case is recorded by Sir B. Brodie, in 
which a hmb was amputated on account of encephaloid disease orioi- 
nating in the lower part of the femur, and the patient continued in 
good health at the period the case was related, which was more than 
four years after the operation! . In a case where I removed the limb, 
on account of encephaloid disease originating hi the head of the tibia, 
I saw the patient hi perfect health at the end of two years from the 
time of the operation. In several other cases I have had the opportu- 

* Museum of the Royal College of Surgeons, 
t Diseases of the Joints. Edit. 2. p. 193. 

13* 



150 TUMORS OF BONE. 

nity of observing patients for shorter periods after amputation, during 
which there had been no return of the disease ; and in four cases of 
encephaloid disease, originating in the femur, and terminating fatally, 
I found, on examining the body of each patient, no encephaloid deposit 
in any other bone or in any of the softer organs. In one of these 
cases, a child, thirteen years of age, died with an enormous enlarge- 
ment of the thigh, from encephaloid disease, which had originated in 
the femur, and not a trace of encephaloid deposit was found in the in- 
guinal absorbent glands, or elsewhere. Every organ in the body was 
perfectly sound. Under these circumstances I much regretted that 
the limb was not amputated in an early stage of the disease. The 
> question of an operation had been anxiously considered, but at a peri- 
od when the disease extended so high up the thigh that it would have 
been necessary to amputate at the hip-joint, and I could not but appre- 
hend the system was too much enfeebled to sustain the shock of that 
operation. 

But there is evidence of the opposite kind. In a case recorded by 
Mr. Lawrence, death occurred shortly after the amputation of a limb, 
on account of encephaloid disease originating in the head of the tibia; 
and on examining the body, encephaloid deposits were found in the 
liver, also in the inguinal absorbent glands*. In another recorded 
case, the arm was amputated on account of encephaloid disease com- 
mencing in the humerus. The patient recovered from the operation, 
but a year afterwards, his health began to decline ; his eye protruded 
from its socket, a tumor appeared upon the cranium, and another in 
the axilla, and he died fifteen months after the amputation. These 
tumors were found to consist of encephaloid substance, and there were 
similar deposits in the lungs and elsewheref. In the case of a young 
female, whose thigh I amputated on account of encephaloid disease 
originating in the lower part of the femur, the stump healed soundly, 
but she died about six months after the amputation, from encephaloid 
.disease in the lungs. 

The frequency with which encephaloid disease in soft parts thus co- 
exists with, or occurs subsequently to, the appearance of this disease in 
bone, becomes, therefore, an important subject for investigation ; and 
it requires the accurate record of a large series of facts, to determine 
the degree of confidence with which a limb may be amputated when 



* Medico- Chirurgical Transactions, Vol. xvii. p. 42. 

t Medical Gazette, April, 1835. Commnnicated by Mr. Clough, of Manchester. 



TUMORS OF BONE. 151 

the seat of encephaloid disease, which commenced in, and is as yet, 
apparently confined to the bone. It is true that there have been cases 
in which this disease, originating in bone, was strictly a local malady, 
and in which, therefore, the removal of it by operation could have been 
undertaken with the expectation of permanent success. But there 
have also been cases in which encephaloid - disease, apparently com- 
mencing in bone, has ultimately presented the same evidence of its 
being a constitutional and malignant disease, as in the instances of its 
commencement in any of the softer organs. 

In regard to the important question of submitting the encephaloid 
disease of bone to operation, the following suggestions are offered in 
accordance with the pathological views generally adopted in respect to 
other malignant diseases : that the disease is most probably always at 
first local, and continues so until the circulating fluids and constitution 
become affected ; that from the part in which the disease commences, 
some of the morbid matter passes into the blood-vessels or absorbents, 
and poisons the blood, and thus gives rise to the formation of secondary 
tumors in other parts of the body. If, therefore, the original en. 
cephaloid tumor is removed before the blood has become poisoned, the 
disease will not return ; but, if the morbid matters have already en- 
tered the circulation, it will be reproduced in other parts of the body. 
According to these views, the encephaloid tumor of bone should be re- 
moved as early as possible ; and, of course,.- before an operation is de- 
termined upon, the greatest pains should be taken to ascertain whether 
the absorbent glands and the internal organs are healthy. Emaciation 
of the body, with quickness of the pulse, dryness of the skin, and sal- 
lowness of the countenance, are indications of the existence of malig- 
nant disease in internal organs, and particularly in the absorbent 
glands. But in some organs, especially in the liver, encephaloid de- 
posits may exist without affording indication of their presence, either by 
disturbing the functions of the affected organ, or by affecting the gen- 
eral healthy aspect of the body. Such are the difficulties which beset 
this important subject of the diagnosis of the encephaloid tumor of 
bone. 

4. TUMOR OF BONE COMPOSED CHIEFLY OF FIBROUS TISSUE. 

Under this head, it is intended to comprise a large number of the 
tumors of bone, "presenting, on the first view, various features, yet, 
when closely examined, not manifesting such distinctive characters as 



152 TUMORS OP BONE. 

to warrant the distribution of them into separate species. Many of 
these tumors are composed of a grey, dense, fibrous tissue, apparently 
identical with that composing the fibrous tumors of the uterus ; whilst 
others present, at least to the naked eye, no trace of fibres, but are 
apparently composed of a firm, compact, whitish or yellowish, opaque 
substance. When, however, a comparative examination is made of 
some of these apparently different tumors, no real difference between 
them is recognized ; they are found to yield gelatine by boiling, and 
to agree in their microscopic characters. Nor are there well sustained 
differences between them in respect either of their vital organization, 
or in the circumstances of their history. Cartilage not being a clearly- 
marked element in these tumors, I have abstained from applying to 
them the term fibro-cartilaginous. Osseous substance, either in mi- 
nute, isolated portions, or in larger masses, is frequently found inter- 
mixed with the softer constituent of these tumors. 

To the foregoing general view of these tumors, other particulars of 
their history are added. They arise indifferently from the outside, or 
in the interior of bones ; and in the latter case, with the growth of the 
tumor, the walls of the bone are either absorbed, or expanded around 
it. Instances have occurred of [the growth of such tumors from more 
than one bone in the same individual ; and there have been instances 
of their growth to an enormous size. In the museum of St. Barthol- 
omew's Hospital there is part of a fibrous tumor, which grew from the 
humerus, and measured three feet in its circumference. In some in- 
stances, these tumors have exhibited a feature of malignancy in the 
tendency to reproduction after their removal by operation. In the 
museum of St. Bartholomew's Hospital there is the portion of a lower 
jaw, with a fibrous tumor growing from its alveolar border, which was 
removed by Mr. Lawrence. It was followed by the growth of a similar 
tumor from the remaining portion of the bone. A large fibrous tumor, 
which grew from the scapula, was removed in the hospital by Mr. 
Skey. Another tumor, of the same kind, grew in the same situation, 
and some months afterwards, the patient died with similar tumors in 
his chest. 

The museum of St. Bartholomew's Hospital contains examples of 
fibrous tumors growing from the following bones, — lower jaw*, hu- 
merus! , femur^, scapula§. In the museum of the Royal College of 

* First series, Nos. 149, 150, &c. t Thirty-fifth series, No. 10. 

t First series, No. 22. § Thirty-fifth series, No. 51. 



TUMORS OF BONE. 153 

Surgeons there are several examples of fibrous tumors growing from 
the upper and lower jaws. By the liberality of Mr. Luke I am en- 
abled to represent a fibrous tumor originating within the antrum, which, 
with part of the jaw, was removed by him in the London Hospital*. 

It is scarcely possible to establish, during fife, any satisfactory di- 
agnosis between the cartilaginous and fibrous tumors of bone, except 
in the instances where the cartilaginous tumor presents a well-marked 
noduled exterior : in other respects the features of the fibrous and 
cartilaginous tumors are the same ; both are painless, well-defined in 
their boundaries, and immediately surrounded by healthy structures ; 
both are of slow growth, and in some instances acquire a large size ; 
and in both there is the same uncertainty respecting the mode of con- 
nexion of the tumor with the bone, which would determine the question 
of removing with the tumor the bone from which it has arisen. 

5. TUMOR OF BONE COMPOSED CHIEFLY OF SOFT, GELATINOUS SUB- 
STANCE. 

Under this head I shall describe a tumor of bone originating!; in the 
deposition of a soft, gelatinous substance into its cancellous texture. 
Then, with the progressively increasing morbid deposit, the walls of the 
bone become absorbed, and a soft, readily compressible, and elastic 
tumor is formed, which is found to consist of a transparent, semi-fluid, 
gelatinous substance, contained in cells, bounded by thin, membranous 
septa. The following is a history of this disease, occurring in the bone 
of a finger, in a case which was under the care of Mr. Lawrence, in 
St. Bartholomew's Hospital. 

A man, sixty-five years old, had been healthy from birth, and both 
his parents had been healthy and long-lived. Rather more than a 
year ago, he noticed a swelling in the first phalanx of the right fore- 
finger : it was moderately firm, gave him little pain, but gradually 
increased. Six months ago, a lancet was thrust into it, and some 
blood, with a watery fluid, was discharged, and ulceration of the open- 
ing ensued. A seton was afterwards passed through the swelling, and 
immediately afterwards it rapidly increased. The hand was amputated 
at the wrist-joint, and in the examination of the diseased parts, the fol- 
lowing particulars were observed. The tumor was of a globular form, 
soft and elastic, and about two inches and a half in diameter. It en- 

* Plate 16, fig. 8. 



154 TUMORS OP BONE. 

veloped the first, with part of the second phalanx of the fore-finger : 
its interior consisted of a semi-fluid, jelly-like substance, contained 
within cells formed by dense, white, fibrous bands. The tumor closely 
surrounded the bone, which was rough in one situation, while, in 
another, part of its wall had disappeared. Within the bone, gelatinous 
substance was deposited, like that of which the tumor consisted. Mr. 
Paget submitted this substance to microscopic examination, and found 
that it possessed none of the characters of cartilage, but apparently 
consisted of a structureless, viscid jelly. In the museum of St. Bar- 
tholomew's Hospital there is an example of this tumor growing from 
a rib*. 

It might be supposed that the gelatinous tumor of bone here des- 
cribed is but a softened enchondroma ; but looking to the other parts 
of its history, it appears more analogous to the gelatiniform cancer of 
other tissues, and this view of it is supported by cases that have occur- 
red, wherein the gelatinous deposits among soft parts were combined 
with the same deposits in the diploe of the frontal and occipital bones, 
as well as upon the ribsf . 

6. TUMOR OF BONE COMPOSED CHIEFLY OF FATTY SUBSTANCE^. 

Here it is intended to describe a peculiar degeneration of the tissue 
of bone, accompanied by the formation of a tumor around it. The dis- 
ease appears to commence in the deposit of a yellow substance into the 
medullary canals of the bone ; hence the colour of the bone is first 
changed, and then its texture becomes converted into a soft, crumbling, 
greasy substance. Small cells, filled with a glairy fluid, and short, 
white, brittle fibres, resembling the hairs of a toothbrush, have been 
found dispersed through the fatty substance. Osseous granules and 
laminae have also been found in it. As the disease advances, the mor- 
bid deposit extends beyond the limits of the bone in the form of a cir- 
cumscribed tumor. 

This disease, in its advanced stage, manifests its worst features of 
malignancy in its tendency to spread indefinitely through the surround- 

* First series, No. 115. 

t Case of Gelatiniform Cancer, in which nearly all the Organs of the Body contain- 
ed Colloid Tumors. By John. C. Warren, M.D, Medico-Chirurgical Transactions, 
Vol. xxvii. Cruveilhier. Anatomie Pathologique. Cancer Areolaire des Os. Planche 1, 
XXI livraison. 

I The term lardaceous has been applied to this tumor; but the same term has been 
applied to morbid substances of a different character. 



TUMORS OF BONE. 155 

ing structures, "with the assimilation of these to its own nature. In an 
instance of this disease originating in the superior maxillary bone, all 
the surrounding cellular tissue, and the adjacent absorbent glands, be- 
came filled with fatty substance, similar to that of the tumor of the 
bone. Hard tubercles have formed in the skin covering the tumor ; 
and in the further progress of the disease, ulceration, commencing in 
the integuments, has extended into the morbid structure, and widely 
into the parts around it. 

The tendency of the disease to spread indefinitely through the parts 
in its neighbourhood, sufficiently explains the fact, that operations for 
the removal of this tumor of bone have been generally unsuccessful. 

The museum of St. Bartholomew's Hospital contains a specimen of 
the disease here described, originating in the superior maxillary bone*. 
It also contains two other specimens, which apparently consist in a sim- 
ilar degeneration of the osseous tissue, but unaccompanied by tumor. 
In one of these, the disease extends through the os innominatumf ; 
and in the other, it occupies the entire thickness of the shaft of the 
tibia, in about the extent of its lower thirdj. 

7. TUMOR OF BONE, COMPOSED OF A SOFT, VERY VASCULAR SUB- 
STANCE, HAVING THE CHARACTERS OF ERECTILE TISSUE. 

This form of tumor is of rare occurrence. In the case of a boy in 
St. Bartholomew's Hospital, under the care of Mr. Lloyd, the disease 
originated in the cancellous texture of the lower jaw ; and, in its pro- 
gress, widely separated the walls of the bone, and thence, protruding 
into the mouth, presented a very vascular surface of a mottled red and 
purple colour, resembling the exterior of some nsevi. The tumor was 
not tender to the touch, and had not been accompanied by pain ; it 
was once destroyed by caustic to the level of the alveolar border of the 
jaw, but was quickly reproduced ; it was then wholly removed with the 
portion of the jaw in which it originated, and the cure was permanent. 
The morbid substance was found imbedded in the cancellous texture of 
the jaw ; it was soft, of a dark red colour, closely resembling the tis- 
sue of healthy spleen§. Dupuytren recorded an instance of this dis- 
ease, also originating in the cancellous texture of the lower jaw in a 
young person ; it projected into the mouth, and was of a deep red col- 
our. A puncture was made in it, from which only blood issued. The 

* First series, No. 151. t Ibid. No. 45. 

% Ibid. No. 78, Plate 4, fig. 4. 

§ Museum of St. Bartholomew's Hospital, First series, No. 23, Plate 13, figs. 1, 2, 



156 TUMORS OF BONE. 

tumor and the portion of the jaw with which it was connected were re- 
moved ; and it is stated that the morbid substance closely resembled 
the tissue of spleen*. Breschet also recorded an instance of this dis- 
ease originating in the head of the tibia. The interior of the bone had 
disappeared, and its place was occupied by a morbid growth, resemb- 
ling the parynchyma of the spleenf. It may perhaps be doubted, 
whether this was not an example of the simple sanguineous tumor of 
bone, which is to be next described. 

The histories which have been adduced of this erectile tumor of bone, 
if it may be so designated, are sufficiently clear, in respect to the ex- 
ternal characters of the disease, to lead to its recognition, when not 
concealed by the walls of the bone expanded over it, or by the perios- 
teum, or by other structures investing it. In the case where I had the 
opportunity of witnessing the examination of the internal structure of 
the morbid growth, it bore a close resemblance to certain nsevi, consist- 
ing, like them, apparently of dilated blood-vessels, with a fibrous tissue 
occupying their inter-spaces ; hence, in a section, the tumor presented 
a cribriform appearance, the orifices being apparently those of divided 
blood-vessels. The evidence which can be adduced is in favour of re- 
moving the portion of bone in which the disease originated, as the secu- 
rity against its reproduction. 

8. TUMOR OF BONE, COMPOSED CHIEFLY OF BLOOD. 

The tumor here intended to be described consists of blood enclosed 
in a cyst. The cyst is composed of osseous substance and its perioste- 
um, or in some parts only of the periosteum and surrounding tissues ; 
hence the tumor is, in some instances, firm and resisting throughout ; 
and in others, soft and yielding in portions of its surface. The con- 
tents of the cyst are blood, fluid, or coagulated — or fibrin, in solid clots 
or layers. The inner surface of the cyst often presents a sort of net- 
work of fleshy cords, and thus bears some resemblance to the inside of 
the ventricles of the heart. 

This tumor, I believe, always originates in the cancellous texture, 
generally within the articular end of a bone, and most frequently with, 
in the condyles of the femur, or the head of the tibia. The process 
by which the tumor is formed appears to be this, — blood is effused into 
the cells of the cancellous texture ; as its quantity increases, the cells 

* Lecons Orales. 

t Repertoire General d' Anatomic, t. ii. p. 170. 



TUMORS OF BONE. 157 

become enlarged, the septa between them absorbed, and at length the 
walls of the bone become expanded into a globular cyst, of varying 
thickness and extent. Accordingly, in an early stage of the disease, 
the blood is found in cells, intersected by fibres and laminae, the re- 
mains of the original fabric of the bone, and, in a more advanced stage, 
in a single cyst. In instances where, from the feeling of fluctuation, 
it was thought that suppuration had taken place in the tumor, and an 
opening was made into it, blood was freely discharged, and an enlarge., 
ment of the tumor was generally the immediate consequence of such 
proceeding. 

When this disease has been left to itself, ulceration of the skin and 
other coverings of the cyst has usually taken place, and there has been, 
profuse hemorrhage from the ulcerated opening. 

The cause of the rupture of the medullary vessels, and of the eon- 
sequent production of the blood-tumor of bone, as it has been aptly de- 
signated, appeared, in a case recorded by Mr. Travers, where the dis- 
ease was seated in the clavicle, to have been external violence applied 
to the bone*. But in other cases, no such cause has existed. In an 
instance of this disease originating in the condyles of the femur, in 
which I amputated the thigh at its middle, an unsoundness of the bone 
extended from the tumor to the point of amputation ; and there was a 
similar unsound state of the shaft of the tibia, both bones presenting 
an ecchymosed appearance from minute effusions of blood through their 
compact tissuef. And in instances where the opportunity has occur- 
red of injecting the arteries of the limb, the fluid has been very freely 
poured out from a multitude of minute orifices upon the internal sur- 
face of the cyst. In the majority of instances, there has been no en- 
largement or other change in the principal arteries of the limb, or in 
the vessels immediately connected with the affected bone. 

The sanguineous tumor of bone does not usually occur in children, 
or after the middle period of life ; it is, in general, accompanied by 
severe pain, and is of slow growth. But it must be admitted, that 
there are no circumstances exclusively belonging to the history of this 
tumor whereby it can be distinguished from other tumors of bone, or 
even from other affections of the joint into which the tumor, from its 
situation, may happen to project. 

Instances of this tumor have occurred in the following bones, — the 

* Medico- Chirurgical Transactions, Vol. xxi. 

t Museum of St. Bartholomew's Hospital, First series, No. 220, Plate 14, fig. 5. 

14 



158 TUMORS OF BONE. 

tibia, especially its head ; the femur, especially its condyles ; the clavi- 
cle*, and the scapulaf . With respect to the treatment of the disease, 
it can only admit of the amputation of the limb, or of the excision 
of the affected bone, as in the case recorded by Mr. Travers, where 
nearly the whole of the clavicle was successfully removed by opera- 
tion. 

In an instance of sanguineous tumor originating within the condyles 
of the femur, where I amputated the thigh at its middle, it was con- 
sidered probable, from the ecchymosed condition of the tibia, and of 
the femur to its amputated extremity, that other bones had under- 
gone a similar alteration ; yet, in the sixth year after the amputation, 
I ascertained the patient to be in good health, and with a perfectly 
sound state of the remaining portion of the thigh. In this instance, 
moreover, whilst the large cyst, fcrmed by the expanded condyles of 
the femur, was filled by fluid and coagulated blood, there were distinct 
portions of a soft substance attached to the inside of the cyst, so close- 
ly resembling brain-like matter as to suggest that the sanguineous tu- 
mor of bone may be a variety, or the incipient stage, of encephaloid 
disease. 

9. TUMOR OF BONE CONSEQUENT ON THE PRODUCTION OF ENTOZOA 

WITHIN IT. 

The globular hydatid, or acephalocyst, has been in a few instances 
developed within bone ; and there is a case recorded, in which the en- 
tozoon, Cysticercus cellulosse, was found within the first phalanx of a 
fore-finger $. The production of parasitic animals in bone is according- 
ly to be regarded among its pathological phenomena ; and as the accu- 
mulation of them in bone, has been usually followed by expansion of its 
walls, it has appeared that this subject would be properly considered 
under the head of the Tumors of Bone. 

Globular hydatids have been found in bones of every form. Usually 
they have been developed only in a single bone ; in a case, however, 
which occurred in St. Bartholomew's Hospital, I found them in two 
bones — the os innominatum and the sacrum ; and in the history of ano- 
ther case, it is stated that the entire osseous system was beset with tu- 
mors containing hydatids. § 

* Medico-Chirurgical Transactions, Vol. xxi. 
1 Edinburgh Medical and Surgical Journal, Vol. xvi. 

t Surgical Clinique of Professor Junghen : — Man, aged twenty-one, admitted Janua- 
ry, 1841, into the Charite of Berlin. § Ibid. 



TUMORS OF BONE. 159 

The development of hydatids in bone has not, in general, been ac- 
co mpanied by pain or irritation of any kind ; but, as the consequence 
of their increasing number, the following changes have occurred in the 
bone itself — first, the expansion of its walls, either generally, so as to 
produce an enlargement of the whole bone, or in a limited extent, so 
as to produce a well-defined tumor ; then absorption of the walls, in 
one or more situations, has ensued, permitting the escape of the hyda- 
tids from the bone into the soft parts around it. The presence of the 
hydatids in the soft parts contiguous to the bone has excited suppura- 
tion, so that, on puncturing the swelling they formed, puriform fluid 
mixed with the hydatids has been discharged. Further, it has happen- 
ed that during the absorption of the walls of a bone filled by hydatids, 
a slight muscular effort caused the bone to snap, and, in such a case, 
the occurrence of the fracture afforded the first indication of serious 
mischief in the bone*. Hydatids developed in other organs are con- 
tained in adventitious cysts ; and there appears to be a similar struc- 
ture connected with their formation hi bone, a smooth white membrane 
being found closely adherent to the walls of the cavity in the bone in 
which the hydatids are lodged. The following case furnishes a good 
illustration of the circumstances connected with the formation of hyda- 
tids in bone. 

A woman, aged fifty-four, was admitted into St. Bartholomew's Hos- 
pital, having a globular and somewhat pendulous tumor, about the size 
of the closed hand, situated upon the nates, directly over the right 
sacro-iliac symphisis. She stated it had been five years in progress. 
A few weeks before her admission, it had been punctured, and puru- 
lent fluid mixed with hydatids was discharged. The tumor again en- 
larged to its original size, and on being punctured a second time, only 
purulent fluid escaped. A free incision was now made into the tumor, 
with the effect of discharging a large quantity of hydatids, with frag- 
ments of bone and purulent fluid. Severe constitutional derangement 
ensued, which in a few weeks was fatal. 

On examination, numerous globular hydatids were found in the inte- 
rior of the right os innominatum, and also within the sacrum. In both 
these bones, the cancellous texture had disappeared, and the surround- 
ing walls were much thinned, and widely separated from each other, a 
large cavity being thus formed in the bone, in which the hydatids were 
lodged ; there were also apertures in the walls of each bone, through 

* Case of Hydatids in the Tibia. By W. J. "Wickham, Esq. London Medical and 
Physical Journal, Vol. lvii. 



160 TUMORS OF BONE. 

which, some of the hydatids had escaped into the surrounding soft 
parts. The cavity in the sacrum communicated also with the spinal 
canal, in which there were numerous hydatids. A smooth white mem- 
brane lined the cavity in the os innominatum and sacrum. There was 
a mass of hydatids between the extensor muscles of the spine, which 
was unconnected with the contiguous bones, and another mass in a cyst 
attached to the ovary. On examining the acephalocysts found in the 
bones, by the aid of the microscope, the enchinococcus was discovered 
in some of them, a fact proving the identity of this hydatid in bone 
with that found in the human liver, urinary bladder, subcutaneous cel- 
lular tissue, and other organs — for in the acephalocyst hydatids from 
these several parts, echinococci have been recognized*. 

The foregoing case shows the uncertainty there may be in the diag- 
nosis of the tumor produced by hydatids, which have escaped from the 
bone where they were formed, into the parts around it. The hydatid 
cyst, protruding from a bone, forms a soft elastic swelling, which has 
been mistaken for the tumor of malignant disease ; and when, by the 
absorption of their membranous cyst, the hydatids have escaped into 
the surrounding cellular tissue, exciting suppuration in it, the swelling 
has presented the characters of chronic abscess. When, owing to the 
increasing accumulation of hydatids in a bone, its walls become thinned 
and expanded, the tumor may then communicate to the fingers the pe- 
culiar crackling sensation which belongs generally to osseous cysts with 
thin sides. But, in some instances, the Avails of a bone filled with hy- 
datids do not become thinned ; they simply expand in such a manner 
as to form a circumscribed, unyielding tumor, having the characters of 
an osseous growth from the bone. Such was the nature of the tumor, 
and consequently the difficulty of its diagnosis, in the remarkable case 
recorded by Mr. Keatef, of " an enormous collection of hydatids be- 
tween the two tables of the frontal bone." The tumor projected from 
the forehead, chiefly over the left orbit, and presented " the shape and 
size of three-fourths of a large orange." Mr. Keate states, that " the 
tumor was evidently of bony growth ; and that the immediate impres- 
sion on his mind was, that it was between the two tables of the frontal 
bone, the external table being pushed forward, causing the convex sur- 
face of the protuberance, and the internal table to be depressed, giv- 
ing rise to the present urgent symptoms," which were intense head- 

* Medico- Chirurgical Transactions, Vol. xxiii, and Vol. xxviii. Miiller, Archiv fiir 
Physiol. 18.36. Medical Gazette, Vol. xxxv. 
t Medico- Chirurgical Transactions, Vol. x. 



TUMORS OF BONE. 161 

aches, vertigo, dimness of sight, nausea, tinnitus aurium. The remov- 
al of the tumor was undertaken, when it was discovered to be a collec- 
tion of hydatids in a cavity circumscribed by the tables of the frontal 
bone, and lined by a thin, transparent membrane. The outer table of 
the skull was taken away, sufficiently for the full exposure of the cavi- 
ty containing the hydatids, which were completely removed. Lint, 
impregnated with a strong solution of sulphate of copper, and also ni- 
trate of silver, was applied to the denuded surfaces of the bone, with 
the view of preventing the reproduction of the hydatids, and with good 
effect. Healthy granulations arose from the inner table of the skull, 
which cicatrized ; the wound healed soundly, and the patient was re- 
stored to perfect health. 

The treatment suited to a case of hydatids in bone will depend on 
the situation and extent of the disease. If the hydatids occupy the 
larger portion of a bone, and have occasioned much destruction of its 
walls, the removal of the entire bone, or of the limb in which the dis- 
ease is situated, may be necessary. But there are cases in which it is 
expedient to scoop out the hydatids from the cavity in the bone ; and 
in treating such cases, it should be borne in mind, that the bone is not 
diseased otherwise than as its walls are expanded, or in part absorbed, 
consequently that no more of the bone will require removal than is 
sufficient to effect the dislodgement of the hydatids from their cells ; 
for when this has been done, and astringents or stimulants have after- 
wards been applied to the bone, no reproduction of the hydatids has 
ensued. Healthy granulations have filled the cavity in the bone, and 
the wound has healed soundly over them. Such was the satisfactory 
result of the treatment of the case of hydatids in the frontal bone re- 
corded by Mr. Keate. 

Another case is recorded, in which the hydatid tumor of bone was 
treated successfully. The tumor, three inches in circumference, pro- 
jected full two inches from the front of the tibia ; its centre was soft, 
but around its base a bony margin could be felt, indicating that the 
disease originated within the bone, and had caused the destruction of 
its walls. Applications were made to the tumor, consisting, first of 
caustic potash, afterwards of the actual cautery, by which a cavity in 
the tibia, three inches long and two inches and a half wide, was ex- 
posed, filled with hydatids. The hydatids were removed, and, after 
several exfoliations, the cavity in the bone became filled with healthy 
granulations, which cicatrized, with the power and movements of the 

14* 



162 TUMOBS OF BONE. 

limb unimpaired*. Also, in the case already referred to, where the 
first indication of disease in the tibia was the occurrence of its fracture 
without apparent cause, four inches of the front wall of the bone were 
removed, exposing its interior, containing a tea-cup-full of hydatids. 
The hydatids were taken away, leaving only a thin shell of the bone 
for about two inches of its length. The wound granulated and healed 
rapidly, and the cure was completed without weakening or shortening 
•of the limbf . 

10. TUMOB OF BONE, CONSEQUENT ON THE FOBMATION OF MEMBBA- 
NOUS CYSTS WITHIN IT. 

Membranous cysts are developed in bone, containing a serous or 
•mucilaginous fluid, occasionally mixed with shining particles of a 
spermaceti-like substance. The enlargement of such cysts may be 
accompanied by a partial or general expansion of the walls of the bone. 
These cysts are frequently developed in the upper, also in the lower, 
jaw; and they have been stated to exist in other bones, but it is 
doubtful whether the disease so described was any other than the cir- 
cumscribed abscess, which is, I believe, in all instances lined by a 
membranous cyst. Since the development of the simple membranous 
cyst, containing a serous or mucilaginous fluid, probably occurs only 
in the maxillary bones, the history of this disease is given under the 
head of morbid growths from the jaws. 

GENEBAL CONSEDEBATIONS BELATIVE TO THE DIAGNOSIS AND PBO- 
GBESS OF THE TUMOBS OF BONE. 

I am induced to add further observations on the diagnosis and pro- 
gress of the tumors of bone, in the desire that this confessedly difficult, 
yet most important, subject may here receive all the aid of which it is 
capable. 

In the foregoing histories of the morbid growths from bone, the oc- 
casional combination of different products and structures, in the same 
tumor, has been noticed, as giving rise to difficulties in their diagnosis. 
It has been shown, that some of these tumors participate in the char- 
acters of the morbid growths from soft parts, in respect to changes to 
which they are liable ; and besides, in respect to changes in their 

* Journal de Medecine, Chirurgie, &c, par M. Corvisart, tome xii. Observation sur 
une tumeur du tibia, qui contenait une grande quantite d'hydatis, par M. Cullerier. 
f Case by Mr. Wickham, London Medical and Physical Journal, VoL lyii. 



TUMORS OF BONE. 163 

composition. Thus, to the original constituent of the tumor, a differ- 
ent deposit appears, in some instances, to have been added ; and it is 
probable that, in such cases, the change is generally, if not always, 
from innocent to malignant disease, and not in the reverse direction. 
In the following case, the addition of malignant to innocent disease in 
a tumor of bone appeared well marked. A' man had, for many years, 
a tumor of his clavicle, which presented externally no other features 
than those of simple exostosis. At length |he died from encephaloid 
deposits in various organs ; and, on making a section of the tumor of 
the clavicle, it was found to consist of cancellous osseous tissue, with 
encephaloid matter filling its cells. 

Our objects in practice are, first, to recognize the broad distinctions 
between the innocent and malignant tumors of bone ; and, secondly, to 
be able to decide upon the connexions of the tumor, in addition to its 
nature, as influencing the question of removing the tumor alone, or 
with it, part, or the whole, of the bone from which it has grown. 
The folio wing summary of facts bearing on these conclusions, may 
perhaps be of use — premising that any details they embrace not in- 
cluded in the histories already related, are drawn from other cases 
which have occurred within my personal observation, unless otherwise 
stated. 

Of the Tumors composed of soft substance, but so firm as to be 
incompressible. These tumors are mostly fibrous or cartilaginous ; but 
they are occasionally found to consist of the firmer sort of encephaloid 
substance. 

Of the Tumors which have the hardness and solidity of bone. If 
such a tumor has an even regular outline, is of an oval shape, with its 
long diameter in the axis of the bone — and if besides, in its whole 
extent, it closely surrounds the bone — the probability is considerable 
that it will prove to be the malignant osseous tumor (Osteoid, of 
Mtiller). There has, however, been an instance of a tumor possessing 
such characters, yet proving to be an osseous cyst, with thick solid 
walls, and containing encephaloid substance. If the tumor which pos- 
sesses the hardness and solidity of bone, is of irregular form, and 
noduled or branched on its exterior, its characters are those of the in- 
nocent osseous tumor (exostosis) . The tumor of enchondroma may be 
noduled on its exterior ; but it is just so much less hard and solid than 
exostosis, that it may yield a little to compression. 

Of the Tumors ivMch are so soft as to be readily compressible. 
Most of the compressible tumors of bone are encephaloid in one or 



164 TUMORS OP BONE. 

other of its forms, and consequently malignant. There are, however, 
exceptions, in the instances of tumors composed of soft vascular, in 
some cases apparently an erectile tissue, exhibiting none of the cha- 
racters of malignant disease. 

Of the degree of fixedness of the Tumor, as evidence of the sort of 
connexion it has with the bone. The absolute immobility of the tumor 
is no ground for determining whether it has grown from the periosteum, 
or from the surface of the bone, or from its interior. A tumor which 
has a broad extent of growth in the cellular tissue, immediately adja- 
cent to the periosteum, is often as firmly fixed in its position, and there- 
fore may be as immovable, as the tumor which has originated within 
the bone. The looseness and mobility of a tumor lying upon a bone 
may lead to a wrong conclusion respecting the mode of its origin. An 
encephaloid tumor, which had originated within a rib, and extended 
through the walls of the bone, and thence through the pectoral muscle, 
was felt immediately beneath the skin, and was so freely movable, that 
the removal of it by operation was proposed, in the belief it was wholly 
subcutaneous. Such an error in the diagnosis has arisen in the fol- 
lowing way. The morbid growth originating within the bone, having 
penetrated a small aperture in its walls, then spread widely over its 
surface. The tumor, being thus connected with the interior of the 
bone by only a narrow stalk or pedicle, was so loose and movable, that 
its origin within the bone was not suspected. 

Of the Enlargement and Tortuosity of the Subcutaneous Veins 
ramifying over the Tumor. This condition of the veins is not, as it 
has often been regarded, evidence of malignancy in the tumor of bone ; 
it occurs upon simple inflammatory and rapidly-forming swellings, 
wholly unconnected with malignant disease. The cause of the en- 
largement and tortuosity of the superficial veins, in all instances, is 
probably an obstruction to the current of blood through the principal 
and deep veins of the part. 

Condition of the Absorbent Glands adjacent to the Tumor. The 
absence of enlargement or other change in these glands, is not a sure 
sign of the innocent character of the disease. Occasionally, even in 
the advanced stage of encephaloid disease originating in the femur, 
the femoral and inguinal absorbent glands are not either enlarged or 
altered in structure. 

Anomalous character imparted to the Tumor by the floiv of Blood 
into it from an Ulcerated Artery. Tumors of bone commonly occa- 
sion the obliteration of the arteries they meet in their progress ; but in 



TUMORS OF BONE. 165 

some instances it is otherwise. A tumor growing from a bone has 
occasioned the ulceration of a large artery with which it became impli- 
cated ; haemorrhage then taking place into the tumor, has caused its 
sudden enlargement, and has, besides, given to it an anomalous char- 
acter, greatly obscuring its diagnosis. The following is the history of 
such a case. 

A man was admitted into St. Bartholomew's Hospital, who stated 
that, from his earliest recollection, he had a hard swelling at the upper 
and outer part of his leg ; that, about five months previous to his ad- 
mission, he had several attacks of cramp in his leg, soon after which, a 
swelling rapidly formed, accompanied by a sense of heat in the calf. 
The swelling gradually extended from the knee to the ancle ; and it 
became so large, that in its middle part, its circumference measured 
twenty inches : it was soft and elastic, and the skin covering it was o 
a reddish-purple hue. Various opinions were formed of the nature of 
the disease ; and, on the ground of its uncertainty, the limb was am- 
putated. On examining it, a large quantity of blood, fluid and coag- 
ulated, was found between the soleus and deep muscles of the leg, the 
source of which was ascertained to be an ulcerated hole in the anterior 
tibial artery, at the point of its passage between the tibia and fibula, to 
the front of the leg. The artery at the part where it had given way, 
was immediately surrounded by a mass of fine osseous fibres mixed 
with encephaloid substance, which had grown from the fibula. 

Displacement of Blood-vessels by the Tumor. In the examination 
of morbid growths originating in the lower part of the femur, I have 
found the popliteal artery and vein displaced, and separated from each 
other, to an extent that, from their natural very firm connexion, would 
scarcely be expected. In one case, the popliteal vessels were found 
upon the inner side of an osseous tumor, which had grown from the 
back part of the femur. In another instance, the popliteal vessels 
were displaced to the outer side of an encephaloid tumor growing from 
the femur ; and the artery was separated from the vein to the extent 
of three inches. The following is the history of this case, containing 
other particulars of interest, which was furnished to me by Mr. Law- 
rence, surgeon to the Sussex County Hospital. 

A female, aged thirty-seven, was admitted into the Sussex Hospital, 
with a large swelling occupying the entire circumference of the knee- 
joint ; it was soft and elastic, and the veins ramifying over it were very 
large and tortuous. The thigh was amputated about five inches from 
the hip-joint. The femoral vein, at the part where it was divided, was 



166 TUMORS OF BONE. 

enormously dilated, the valves being, in consequence, ineffective : di- 
rectly the vein was divided, a current of blood rushed from its orifice 
with so much force, that it extended full three feet from the limb. 
This large and unexpected haemorrhage so nearly extinguished life, 
that it was deemed necessary to resort to the transfusion of blood, 
which was done with complete success. Five weeks after the opera- 
tion, the patient left the hospital perfectly well. The condyles and ad- 
jacent part of the shaft of the femur were found in part expanded 
around the tumor, which consisted of encephaloid substance mixed with 
osseous fibres. 

TUMORS OF BONE WHICH PULSATE. 

A remarkable feature, namely, pulsation, is occasionally observed in 
the tumors of bone. There may be either a slight thrill or vibration 
through portions of the tumor, or the deep, heavy pulsation of aneu- 
rism in every part of it. In certain cases, the structure of the tumor 
has been such as apparently to account for its pulsation, but in others 
there has been no other apparent cause of pulsation than the contigui- 
ty of the tumor to a large artery. 

The pulsating tumors of bone are various in their nature, more es- 
pecially those tumors which owe their pulsation to an artery lying in 
contact with them. Most of this class of pulsating tumors consist of 
encephaloid substance, originating either in the head, or lower end of 
the tibia, or in the condyles of the femur, or in the head of the hume- 
rus. In a few cases, the pulsating tumor has consisted only of blood 
enclosed in an osseous cyst, without morbid change in the adjacent 
blood-vessels, or the development of any vascular and erectile tissue ; 
these were instances of the sanguineous tumor of bone deriving pulsa- 
tion from the large artery contiguous to it. In one case which I ex- 
amined, the pulsating tumor, originating in the humerus, consisted of a 
gelatinous substance, forming the thick walls of a large cavity, filled 
by a serous fluid : this, probably, was a cartilaginous tumor, which had 
undergone the central softening and disorganizing process, which oc- 
curs in such tumors*. 

The further considerations on the pulsating tumors of bone will be 
arranged under the following heads. 1. The sources of their pulsa- 
tion. 2. The diagnosis between these tumors and aneurism. 3. The 
treatment. 

* Museum of St. Bartholomew's Hospital, First series, No. 86. 



TUMORS OF BONE. 167 

Three distinct sourees of pulsation have been recognized in these tu- 
mors. 1. The proximity of a large artery. 2. The development of 
blood-vessels and blood-cells, constituting a sort of erectile tissue -within 
the tumor. 3. The enlargement of the arteries of the bone. 

1. There have been, at different periods, in St. Bartholomew's Hos. 
pital, three instances of pulsating tumor, two originating in the upper 
part of the humerus, and the third in the lower part of the femur, in 
each of which, the tumor was considered to be aneurism, until, in the 
examination of the parts, it was discovered that the only source of pul- 
sation was the large artery which, in each case, lay in close proximity 
to the tumor. To these cases, three others may be added ; one of en- 
cephaloid pulsating tumor, originating in the head of the tibia, record- 
ed by Mr. Lawrence*, and two of encephaloid pulsating tumors, origi- 
nating in the lower part of the tibia, communicated to me by Mr. 
Hodgson. These cases presented, on examination, no other source of 
pulsation than the proximity of the tumors to the popliteal artery in 
the first case, and to the arteries of the leg in the two others. The 
following case evidently belongs to the same category. A man, aged 
sixty eight, suffered two severe falls upon the shoulder. Subsequently 
an enlargement of the part ensued, with pulsation in it. The tumor 
was considered to be an aneurism, and the subclavian artery was tied. 
Three weeks after the operation the patient sank. The tumor was 
found to be a mass of medullary substance, to which the axillary arte- 
ry firmly adhered, the vessel itself being perfectly soundf . 

2. In a case of pulsating tumor, originating in the ilium, and pro- 
jecting from both surfaces of the bone, which occurred in St. Bartholo- 
mew's Hospital, tho tumor, upon examination was found to be soft and 
spongy, having small cells dispersed through it, filled with blood. 
Bunches of convoluted vessels could be drawn out of this spongy sub- 
stance, and the whole tumor, when macerated, was reduced to a tissue, 
closely resembling that of unravelled spleen, or placenta^. Here was 
a structure capable of enlargement by the distension of its vessels and 
cells ; and it is highly probable that the rush of blood from the sur- 
rounding arteries into this structure produced the pulsation, which gave 
to the tumor so completely the characters of aneurism. At all events, 

* Medico- Chirurgical Transactions, Yol. xvii. 

t Case of medullary sarcoma engaging the upper portion of the humerus considered 
aneurismal, and for which the subclavian artery was tied above the clavicle, by John 
Nichol, M.D. Edinburgh Medical and SurgicalJournal, July, 1834. 

t Museum of St. Bartholomew's Hospital, First series, Nos. 235 — 238, 



168 TUMORS OF BONE. 

it is certain that the tumor instantly ceased to pulsate when the aorta 
was compressed through the walls of the abdomen ; moreover, that it 
enlarged, and became tense, when the femoral artery below it was com- 
pressed, just as an aneurism under similar circumstances would have 
done. Through the liberality of Mr. John Lawrence, surgeon to the Sus- 
sex County Hospital, I had the opportunity of examining a pulsating tu- 
mor, which originated in the upper part of the femur. This tumor 
was of the size of the head of a full-grown foetus, and composed of 
vessels intermixed with a soft, gelatinous substance. The vessels form- 
ed more than half the bulk of the tumor : they were of the size of 
sewing thread, and very convoluted, and were shown by injection to be 
directly continuous with the arterial system. In this instance, there- 
fore, the structure of the tumor, essentially the same as in the case be- 
fore described, was such as might be considered to account for its pul- 
sation. 

8. In some few cases which have been recorded, the pulsating tu- 
mor of bone was accompanied by an enlargement of the arteries dis- 
tributed through the osseous tissue, to which, therefore, the pulsation 
might be ascribed. Such cases are related by Scarpa* and by Dupuy- 
trenf. There are cases, also, related by Pelletanf, in which the pul- 
sating tumor appeared to have originated in enlargement and rupture 
of the special nutrient artery of the medullary tissue of the bone ; 
and in an instance related by Morgagni§, the foramen in the walls of 
the femur transmitting this artery, had enlarged to the extent that it 
easily admitted the little finger. A case, apparently of the same cha- 
racter as the foregoing, occurred to Mr. Luke, of the London Hospi- 
tal, in which a pulsating tumor originated in the shaft of the femur, at 
the part where the bone had been twice broken. The opinion being 
entertained that the tumor was aneurismal, the femoral artery was tied, 
and the tumor became somewhat diminished. About a month after- 
wards, it again enlarged, and the limb was then amputated. The low- 
er third of the femur was found expanded into a spherical tumor, in 
the interior of which were cells of various size, filled with blood. The 
femoral artery and vein were entire and healthy. The medullary arte- 
ry of the femur wa,s greatly enlarged, and, in the amputation, more 
than forty arteries required the ligature. In this case, however, it 

* Treatise on Aneurism. Translated by Wishart, p. 439, et seq. 

t Lecons Orales, t. iv. p. 60. 

J Clinique Chirurgicale, t. ii., Obs. iv., v. 

§ On Diseases, Book iv., Let. ii., Art. 38, 39. 



TUMOKS OF BONE. 169 

may be a question, whether the general enlargement of the arteries of 
the thigh accompanied the formation of the pulsating tumor, or had 
taken 1 place subsequently, as a consequence of the ligature upon the 
femoral artery. 

Whatever may be the source of pulsation in the tumor of bone, its 
strength and its distinctness are, in every case, materially influenced 
by the degree of density and power of resistance possessed by the 
structures immediately investing the tumor. It may, indeed, be doubt- 
ed, whether any of these tumors would pulsate independently of the 
firm support afforded by the bone, or its immediate coverings. This 
point is well illustrated in the history of a medullary tumor developed 
in the head of the tibia, recorded by Mr. Lawrence, where the tumor 
pulsated in its early stage, but ceased to pulsate directly it had burst 
through the resistant coverings of the bone*. 

The character of the pulsation in the tumor of bone has been, in 
many instances, so perfectly identical with the pulsation of aneurism, 
that the most experienced surgeons have been deceived by it. Thus 
the compression of the arterial trunk leading to the tumor has produc- 
ed, with the stoppage of pulsation, a lessening in the size and tension 
of the tumor, whilst the compression of the artery below the tumor, 
has been followed by increase of its tension and size : further, the com- 
pression of the tumor has caused it, in some degree, to recede ; and on 
slowly remitting the pressure, the sensation has been communicated to 
the fingers of a rush of blood into the tumor. Such certainly have 
been the characters of the pulsating tumor of bone, and they are the 
ordinary characters of aneurism. 

In the next place it is to be observed, that the bruit, or bellows' 
sound, which, under many circumstances, is a distinctive character of 
aneurism, belongs alike, and with equal force, to the pulsating tumor of 
bone. In the case of pulsating tumor of the ilium, which occurred in 
St. Bartholomew's Hospital, the ear resting against the tumor recog- 
nized the strongly-marked bellows' sound of aneurism ; and in the case 
of encephaloid tumor of the pelvis, which has been recorded by Mr. 
Guthrie, it is stated, " that on putting the ear to the tumor, the whiz- 
zing sound attendant on the flow of blood into aneurism could be very 
distinctly heardf ." The bruit or bellows' sound has been recognized, 
not only in the cases where it could be ascribed to the flow of blood 

* Medico- Chirurgical Transactions, Vol. xvii. 

t London Medical and Surgical Journal, August, 1834. 

15 



170 TUMORS OF BONE. 

through the vessels and cells within the tumor, but also in others, 
where the tumor possessed no such structure, and where, consequently, 
the sound recognized in it must have been derived from the pulsations 
of the large artery immediately contiguous to the tumor. There are 
facts which show that a tumor of any sort, situated close to a large ar- 
tery, may so influence the character of its pulsations, that the ear rest- 
ing against the tumor will recognize in it the distinct bruit, or bellows' 
sound : hence we may refer to this source the aneurismal sound heard 
in certain pulsating tumors of bone situated close to large arteries, but 
possessing nothing in their internal structure which would adequately 
explain the pulsation. 

With respect to the treatment of the pulsating tumors of bone, there 
can be but one material consideration, namely, whether the main artery 
leading to the tumor should be tied, in the expectation that, if the chief 
current of blood flowing to the tumor be stopped, it will cease to grow, 
and gradually disappear. Here the difficulty lies in the diagnosis be- 
tween the two classes of pulsating tumors of bone — those which do, 
and those which do not, possess an internal structure adequate to pro- 
duce their pulsation. In a case of encephaloid tumor deriving its pul- 
sation from the large artery contiguous to it, the ligature of the artery 
above the tumor would be of no avail ; but a different view would be 
taken of the probable effect of the ligature of the main artery leading 
to a tumor, composed chiefly of blood-vessels, or blood-cells, arranged in 
the form of erectile tissue, or otherwise. In instances of such a form 
of disease, the ligature of the main artery of the limb has been fol- 
lowed by the gradual disappearance of the tumor, but not always by the 
permanent cure of it ; for in some of these cases, the tumor re-appear- 
ed at a distant period from the operation. On the important question 
of the results of treatment, the following evidence is recorded : — 

Pulsating Tumor just heloiv the Knee. A man, aged forty-three, 
was attacked with a sharp and fixed pain in the knee. Soon after- 
wards, a pulsating tumor was recognized just below the joint. The 
disease advanced very gradually during the next two years, and at the 
end of that time, presented the following characters : — The head of the 
tibia was enlarged to twice its natural size, and every where pulsated, 
and with each pulsation there appeared to be an expansion of the tumor. 
Compression of it was accompanied by a peculiar crackling sensation ; 
and at one point, an aperture in its osseous parietes was recognized. 
M. Lallemand tied the femoral artery in the upper third of the thigh. 



TUMOKS OP BONE. 171 

the operation was followed by a gradual subsidence of the disease, and 
the return of the bone to its natural condition. Three months after 
# the operation, the patient was able to walk without crutches. No men- 
tion is made of any recurrence of the disease*. 

Pulsating Tumor just beloiv the Knee. In a man, aged thirty-two, 
a pulsating tumor appeared at the inner side of the tibia, just below the 
knee. In a year from its commencement, the circumference of the tu- 
mor was about equal to that of the palm of the hand. Dupuytren tied 
the femoral artery in the middle of the thigh. The pulsations of the 
tumor directly ceased, but, a few days afterwards, they returned in a 
slight degree. The pulsations again ceased, and the tumor gradually 
disappeared. Seven years afterwards, the tumor re-appeared, and ac- 
quired a large size, but was without pulsation. Dupuytren then ampu- 
tated the limb ; the wound bled so profusely, that twenty-four vessels 
required the ligature. The patient recovered. On examining the am- 
putated limb, the tumor was found to be composed of numerous cysts ; 
some filled with a gelatinous matter, others with coagulated blood. A 
fine membrane fined the cysts, through which vessels were abundantly 
distributed in the form of a close networkf. 

Pulsating Tumor just above the Wrist. A pulsating tumor origi- 
nated in the lower part of the radius of a man, aged thirty-six years. 
M. Roux tied the brachial artery in the middle of the arm ; the tumor 
became flaccid, ceased to pulsate, and underwent no further change 
for five weeks ; it then again increased with the return of pulsation. 
M. Roux amputated the arm. The radius, through its lower fourth, 
had disappeared ; the pulsating tumor which occupied its place, was 
composed of cells filled with blood. 

Pulsating Tumor just beloio the Knee. In a man, aged forty-five 
years, the head of the tibia was enlarged, and presented from its outer 
side, a distinct projection as large as the closed hand. When the tu- 
mor had existed for several months, pulsation in it was discovered, but 
the impulse was unaccompanied by bruit de soufflet. M. Roux tied 
the femoral artery ; the tumor collapsed, ceased to beat, and gradual- 
ly decreased, the head of the tibia recovering its natural form and 
size J. 

* Observations sur un tumeur aneurismale accompagnee de circonstances insolites 
par M. Lallemand, Repertoire general d'Anatomie et de Physiologie, tome ii. 

t Lecons Orales, tome iv. p. 60. 

% Bulletin de l'Academie Royale de Medecine, seance du Fe'vrier, 1845. Faits et re- 
marques sur les tumeurs fongueuses sanguines ou aneurismales des os, par M. Roux. 



172 TUMORS OF BONE. 

The foregoing cases furnish sufficient evidence to prove that the pul- 
sating tumor of bone, which is composed of blood alone, or of blood 
contained in the vessels and cells of an erectile tissue, may be arrested ' 
in its progress by the ligature of the main artery of the limb. More- 
over, it deserves attention, that the ligature of the artery was, in two 
of these cases, followed by reparative processes in the bone, effecting 
the restoration of its natural size and firmness. 

In a case of pulsating tumor of bone, which, from its situation, and 
other circumstances, might be favourable for the ligature of the main 
artery of the limb, difficulties in the diagnosis are likely to arise — first, 
in ascertaining that the tumor is not aneurism, and, secondly, in decid- 
ing it to be a form of pulsating tumor which is curable by operation. 
In the case of pulsating tumor of the ilium, which occurred in St. Bar- 
tholomew's Hospital*, after the most careful consideration of its circum- 
stances, a ligature was placed around the common iliac artery, in the 
belief that the tumor was an aneurism. There was, indeed, in this 
case, one circumstance from which doubt did arise, as to the tumor be- 
ing aneurismal ; namely, the existence of a small movable piece of 
bone, involved in the coverings of the tumor, this being an ordinary 
feature of the tumor of diseased bone, but not of aneurism. 

Further illustration of the difficulty in the diagnosis between the tu- 
mor of aneurism and of diseased bone is afforded in the following case. 
A soldier, aged nineteen, while walking, suddenly felt pain in his left 
ham, and immediately afterwards a swelling in the ham began, which 
in twenty-four hours increased to the size of a goose's egg, and dis- 
tinctly pulsated. The femoral artery was tied, but without arresting 
the progress of the tumor ; it continued to increase, and the patient 
sank. The tumor was found to be situated deeply in the ham, and was 
closely adherent to the periosteum of the femur and of the tibia. In 
its exterior portion, there were cysts containing a sanguineous fluid ; 
its interior consisted in part of fibrous tissue disposed in lobes, and in 
part of a softer substance, containing cells filled with serous fluid. The 
internal structure of the femur and of the tibia was healthy. The 
popliteal artery was healthy ; it ran over the tumor between the sacs 
of fluid on its surface, through which, it appeared, the pulsation of the 
artery was communicated to the whole mass of the tumor. The right 
lung was filled by brain-like substance. The disease here described, in 
the mode of its commencement, and in its characters, presented so 

* Medico- Chirurgical Transactions, Vol. xxviii. 



TUMORS OF BONE. 173 

completely the features of popliteal aneurism, that, in the belief of 
its being so, the femoral artery was tied. The case is accordingly 
described as an instance of " fibrous tumor, mistaken for an aneu- 
rism*." 

•No observations of much value can be offered in aid of the diagnosis 
between the several forms of pulsating tumor arising in bone, with the 
view of distinguishing those which are curable by operation. The en- 
cephaloid tumor may be soft and readily yielding to compression, or 
resilient ; and so has been the tumor composed of a sort of erectile tis- 
sue, unaccompanied by any peculiar morbid deposit. Nor can assis- 
tance in the diagnosis be gamed by attention to the nature of the cov- 
erings of the tumor, whether these be soft and readily yielding, or firm 
and resisting, or but moderately firm, and yielding with crepitation, 
the latter circumstance depending on the presence of a thin osseous 
cyst enclosing the soft contents of the tumor. But the osseous cyst 
may be thick and unyielding ; it is, besides, found in different cases to 
enclose various fluid or solid morbid products, and accordingly it affords 
no information respecting the internal constitution of the tumor. 

Instances have occurred of pulsating tumors arising from more than 
one bone in the same individual. One such case is recorded by Scar- 
pa. On account of a pulsating tumor originating in the tibia, the limb 
was amputated above the knee. Five years afterwards, the end of the 
stump enlarged and pulsated. The man died from exhaustion ; and, 
on examining the remaining portion of the amputated thigh, it was 
found " full of bloody polypous clots, similar to those in an aneurism. 
The substance of the os femoris had been absorbed from the apex of 
the stump to the vicinity of the great trochanter, the periosteum of all 
this portion of the thigh-bone was thickened, interspersed with blood- 
vessels very much dilated, and converted into a sheath which supplied 
the place of an aneurismal sacf." The folio whig is a remarkable in- 
stance of pulsating tumors originating in many bones. An old man, 
in the course of two years, had seven pulsating tumors developed in 
different parts of the skeleton. He died comatose. The body was ex- 
amined, in the presence of Scarpa, by Dr. Borta. The arterial sys- 
tem having been injected from the aorta, the tumors were then exam- 
ined. Each tumor was invested by the periosteum, which was thick, 
spongy, and very vascular. Beneath it, was a reddish-yellow mass, 

* Observations in Pathology, by Dr. Kerst: Utrecht, 1839. 
t Treatise on Aneurism. Transl. by Wishart, p. 439. 

15* 



174 TUMORS OF BONE. 

soft in some parts, elastic in others, traversed by a net-work of capilla- 
ries. All the tumors presented the same structure*. A case, still 
more remarkable, is recorded by Cruveilhier, in which numerous tu- 
mors formed in various parts of the body, all strongly pulsating, and 
presenting, besides, a distinct bruit de soufflet. Upon examination, 
some of these tumors were found to have originated in the bones ; but 
there were others wholly unconnected with them. All the tumors pre- 
sented the same structure, being composed of cells of various size, di- 
vided by fibrous threads, and filled with bloodf. 

OSSEOUS GROWTHS, ARISING, IN CONSIDERABLE NUMBERS, FROM 
THE SKELETON, AND IN THE SOFT TISSUES. 

This section will comprise certain cases of rare occurrence, wherein 
osseous growths, apparently of constitutional origin, have arisen indif- 
ferently from the bones and in the soft tissues ; and so remarkable, in 
such instances, has been the tendency to the production of these 
growths, that they have appeared in various situations and in considera- 
ble number, either simultaneously or in quick succession ; sometimes 
as the direct consequence of local excitement, but as frequently with- 
out it. Some of these osseous growths, when arising from the skeleton, 
have possessed the cartilaginons base, and primordial structure of gen 
uine exostoses ; whilst, in other instances, the osseous growths from the 
skeleton, and alike from the soft tissues, have appeared to possess no 
cartilaginous base or matrix, but have resembled the outgrowths or cir- 
cumscribed hypertrophies of bone. 

Most of these cases have occurred in early life ; it was then, at 
least, that the production of the numerous osseous growths commenc- 
ed ; and they have continued to increase in size during the growth of 
the body to its full stature, but not afterwards. 

Some of these cases have occurred in several individuals of the same 
family ; and occasionally in a direction to show an hereditary tendency 
to the disease- A man in St. Bartholomew's Hospital had a large os- 

* Scarpa ; Annali Universali di Med. 1830, translated into the Archives Generates de 
Medicine, tome xxiii. et xxiv. 

f Anatomie Pathologique, fol., livraison xxxiii. Toutes les tumeurs pulsatiles etai- 
ent constitutes par un tissu caverneux. dont les areoles fibreusec, tres inegales pour la 
capacite, etaient remplies de sang. Plusieurs de ces tumeurs, la tumeur du genou, la 
tumeur de l'epaule gauche, sont etrangeres aux os, developpees dans l'epaisseur et aux 
depens des parties molles. La tumeur costale, les tumeurs de l'epaule droite, et les tu- 
meurs craniennes sont formees aux depens du tissu osseux. 



TUMORS OF BONE. 175 

seous growth from one femur, and several smaller growths of the same 
kind from the other femur ; also, similar growths from both tibiae, and 
from the bones of the fingers of both hands. All the tumors had form- 
ed in early life, and were now stationary. He stated, that his father 
had bony swellings in various parts of the body ; and I saw two of his 
children, in whom there were osseous growths from the humerus, radi- 
us, and ulna, and from the ribs. 

The following is also an instance of the hereditary character of this 
disease. 

A boy, six years of age, was in St. Bartholomew's Hospital, under 
the care of Mr. Llovd. He had numerous osseous growths from the 
bones of the fingers — from each radius, humerus, scapula, tibia, fibula, 
and from the ribs. Most of the growths were symmetrical, in situation 
and form ; and all those on the right side of the body were rather lar- 
ger than those on the left. The father of this boy came to. the hospi- 
tal. He had several osseous growths, one on each parietal bone, one 
on each humerus, one or the first phalanx of the right forefinger, one 
on each femur, just above the inner condyle, and one on the inner side 
of the head of each tibia. This man stated, that neither his father 
nor mother, nor (so far as he knew) their parents, had such tumors ; 
but that four of his cousins on the mother's side had them. Of his 
own four children, the one in the hospital was alone thus affected. 

By request of the parents, Mr. Lloyd removed the fore-finger of the 
boy in the hospital, on account of the inconvenience he suffered from 
the distortion of it, occasioned by the osseous growth from its first pha- 
lanx. The tumor was found to consist of cancellous osseous substance, 
with wide cells full of soft medulla, and coated by a thin layer of com- 
pact osseous substance. The cancellous tissue of the tumor was con- 
tinuous with that of the bone of the finger. 

Another circumstance in the history of these cases is, that whilst in 
some of them, during the tendency to osseous deposits on the skeleton 
and elsewhere, the urine was deficient in its usual proportion of phos- 
phate of lhne ; in others it was not so — the urine was found to be heal- 
thy, and there was no sign of other derangement in the system, to 
which the occurrence of the disease could be ascribed. 

It must be conceded, that, respecting the pathology of this disease, 
no satisfactory knowledge exists. Whatever information can be furn- 
ished respecting it, either in respect to the pathology, or to curative 
measures, will, I believe, be found in the following histories. 

Mr. Abernethy has recorded the following case : — " A youth, about 



IT 6 TUMORS OF BONE. 

fourteen years of age, was brought to me, whose hack was greatly de- 
formed by hillocks of earthy matter, heaped up upon the spinous pro- 
cesses of the vertebrae. The Hgamentum nuchae was' ossified, so that 
the head was immovably fixed. There were exostoses on the os brachii 
of both arms, and the tendinous margins of the axillae were converted 
into bone, and pinioned his arms so closely to his sides, that it was diffi- 
cult to insinuate the fold of a napkin between them and the chest* 
There was an exostosis on the pelvis, and various others had formed at 
different times, and disappeared. If, in a forcible effort to accomplish 
any purpose which his manacled situation often obliged him to make, 
he accidentally struck his head or any projection of bone, a temporary 
deposition of earthy matter was always the 'result. He had had the 
toothache, and an exostosis appeared on the lower jaw." 

The urine of this patient was examined by Sir Humphry Davy, and 
found to be deficient in the usual proportion of phosphate of lime, and 
accordingly, Mr. Abernethy directed the patient to take phosphoric 
acid in the proportion of one drachm daily, dissolved in such a quanti- 
ty of water as it would slightly acidulate. Whilst he took this medi- 
cine, the urine resembled that of other persons, containing the usual 
proportion of lime, with a surplus of phosphoric acid. On discontinu- 
ing it, the urine directly altered — it contained neither lime nor nhos- 
phoric acid in the right proportion*. 

A girl, fourteen years of age, was admitted into St. Bartholomew's 
Hospital, under the care of Mr. Earle, on account of an osseous 
growth from the upper and inner -part of the humerus. She was ap- 
parently in good health, and, as the growth was increasing, its re- 
moval by operation was proposed ; but other similar growths were dis- 
covered upon the thigh bones, and upon the tibiae, of the existence of 
which the girl was not aware. The idea of an operation was now aban- 
doned. A generous diet was allowed, and five grains of blue pill were 
directed to be taken every night. 

An analysis of the patient's urine was made by Dr. Bostock, who 
reported to me the following results — that before the mercury was ad- 
ministered, it was of low specific gravity, was deficient in the propor- 
tion of phosphate of lime, and contained a considerable quantity of al- 
bumen ; that after the mercury had been continued some days, and be- 
fore salivation was produced, the urine contained the ordinary quantity 
of phosphate of lime, and was in other respects healthy ; and that after 

* Lectures on Surgery, by John Abernethy, p. 169. 



TUMORS OF BONE. 177 

the discontinuance of the mercury, the urine again became deficient in 
phosphate of lhne, and in other respects unhealthy as before. 

Mr. Hawkins has recorded the case of a man, twenty-two years of 
age, in whom a multitude of osseous deposits were formed in various 
parts of the body, many of them independently of the skeleton. His 
general health was good ; the only organ in which any derangement of 
function could be discovered was the skin ; its surface was morbidly 
greasy, but there was no deficiency in the perspiration. One of the 
osseous tumors was removed by operation ; its earthy components were 
carbonate and phosphate of lhne : it had cancelli and an outer shell, 
periosteum, and cartilage ; and its microscopic characters were the 
same as those of true bone. Under the administration of iodide of 
potassium and sarsaparilla, and under the constitutional action of mer- 
cury, many of the tumors disappeared. Diluted sulphuric acid was 
given to this patient, and, during its use, all the tumors which were 
then forming considerably decreased in size*. 

The case of a man, whose skeleton is preserved in the museum of 
the Royal College of Surgeons, was apparently of the same class as 
the foregoing. Numerous osseous growths have arisen from various 
bones, also in the course of the. muscles — some of them projecting into 
the joints, which became in consequence anchylosed. It is remarkable, 
moreover, that in this skeleton, the bones are unusually fight, contain- 
ing less than the ordinary proportion of earthy matter, which, notwith- 
standing, is so abundantly deposited elsewhere. 

* Medical Gazette, May 31, 1844. 



PART III. 



CHAPTER I 



RICKETS. 

It would appear, from some of the recorded histories of rickets, that 
the condition of the osseous system implied by this term is, in certain 
cases, accompanied by fever, continuing to the destruction of life. 
But it is not ordinarily so. The morbid changes in the bones are, in 
general, accompanied by a state of» simple weakness through the rest 
of the system. This is the chief constitutional feature of the disease. 
And yet the changes in the bones, from the state of health to that of 
rickets, are not such as it might be expected would result from a mere 
deficiency of their earthy matter, in the view that a certain amount 
of vigor of system is requisite for the separation of the salts of bone, 
giving to it its proper hardness. But the rickety bone is not simply a 
soft bone ; it undergoes, during the development and subsidence of the 
disease, a series of curious and somewhat complex changes. 

Rickets has been observed in the foetus. In the museum of St. 
Bartholomew's Hospital, there is a foetal skeleton, exhibiting a rickety 
condition of the bones, accompanied by enlargement of the skull, from 
hydrocephalus. In some instances, rickets has commenced immedi- 
ately after birth ; it rarely, however, appears before the fifth or sixth 
month, and the most frequent period of its commencement is between 
eighteen and twenty-four months. It very seldom commences after 
puberty. 

The first indication of rickets in a bone, is a diminution of its firm- 
ness, from the separation of its lamellae and fibres, accompanied by an 
altered character of its medulla. Its tube, cells, and the interstices 



180 RICKETS. 

of its lamellae, and fibres, become filled by a serous fluid; at a later 
stage, this fluid is replaced by a gelatinous substance, which becomes 
organized, and passes into the condition of a moderately firm, elastic 
tissue, with minute cells dispersed through it. Accordingly, at this 
period, the bone consists throughout of a sort of cartilaginous tissue, 
which will bend without breaking, and through which a knife may be 
readily passed. Within this tissue, distinct roundish pieces of a blue- 
ish semitransparent substance are occasionally observed ; these are 
apparently some remains of the original foetal cartilage. Hitherto it 
has been supposed, that the change in the rickety bone consists simply 
in the reduction of it to its cartilaginous elements, and that accord- 
ingly, its chemical condition is the same as that of bone from which the 
earthy matters have been abstracted by an acid ; but, in the recent 
analysis of a rickety bone, it is shown, that besides the diminution of 
its earthy salts, there is also a change in the animal matter, so that the 
extract obtained from it by boiling does not yield either chondrin, or 
the gelatine of bone*. 

The epiphyses are united to the shafts in rickety bones less firmly 
than in healthy bones. Occasionally, the articular ends of rickety 
bones are expanded ; but this occurs only in the joints possessing a 
thin covering of soft parts, such as the wrist, elbow, knee, and ancle. 
In a case which has been recorded, expansion of the ends of the bones 
occurred to a remarkable extent, without any distortion of their shaftsf. 

The following are the principal changes which occur from rickets, 
in the separate bones, and in the several portions of the skeleton. 

The figure of the bones is changed in various directions, determined 
by the weight and pressure they have to sustain, as well as by the 
action of the muscles which surround them. Long bones become 
twisted or bent ; some of these, especially the tibia and fibula, are 
occasionally bent into angles, but more frequently into curves. Flat 
bones become hypertrophied in their cancellous texture, and curved. 
Irregulary-shaped bones expand in certain directions, whereby their 
form is changed. 

* Beitrage zur Physiologischen und Pathologischen Chemie und Mikroscopie, v. Dr. 
F. Simon, Berlin, 1843. The changes in the bones from rickets are well described by 
Guerin, in his Me'moire sur les characteres generaux da rachitisme, Paris, 1839. 

1 Case by Thomas Brayne, Esq., Banbury. Transactions of the Provincial Associa 
tion, Vol. iii., with a representation of the figure of the child, at the age of seven years. 



RICKETS. 181 

In the rickety child, the head is below the standard dimensions, 
from the arrest of its growth ; but this is more marked in the bones 
of the face, than in those of the cranium ; hence, in such individuals, 
the cranium appears large in proportion to the face. " When," Mr. 
Shaw remarks, " we observe the shape of the head in such deformed 
persons, it will be perceived that one general character belongs to 
them ; that whilst the cranium appears unusually large, and capacious, 
the face is remarkably small*." The flat bones of the cranium become 
thick, porous, and spongy — and their outer surface often presents a 
peculiar roughness, resembling the texture of woollen cloth. 

The spine suffers changes in its figures, from the yielding of its: 
weakened fibro-cartilages and ligaments. It becomes curved and twist- 
ed, and its curvatures are either lateral, or in the anteroposterior di- 
rection. A single curve occurs in a portion of the spine, or extends; 
through the whole of it ; or there are two, or three curves, occupying 
the entire spine. In the curvatures of considerable extent, the bend, 
or twist of the spine, is not in general entirely in one direction ; thus 
the extensive lateral curves are usually combined with some degree of 
yielding of the spine in the anteroposterior direction. 

Changes in the form of the bodies and processes of the vertebrae 
ensue in consequence of these distortions ; the bodies lose much of 
their thickness, on their front or lateral aspects, according to the direc- 
tion of the curvature, from the undue pressure which they suffer on 
the concave side of the curve ; and, on the convex side of the curve, 
the articular processes become much augmented in breadth and thick- 
ness, obviously with the effect of adding materially to the strength of 
the distorted portion of the spine. 

The curvatures of the spine ensuing from rickets, do not exhibit 
characteristic features, distinguishing them from the curvatures which 
arise under various other circumstances. And, with respect to the 
consideration of their causes, the whole of these distortions apparently 
constitute but one series ; the causes of distortion being either weak- 
ness in one or other of the structures, whose office it is to maintain the 
spine erect, or irregular action of the muscles on one side of the spine, 
interfering with the balanced actions of the muscles on. its opposite 
sides, which concur to the maintenance of its erect figure. 

* On the effects of rickets upon the growth of the skull, by Alexander Shaw, Esq., 
Medico- Chirurgical Transactions, Vol. xxvi. 

16 



182 KICKETS. 

What are the circumstances which determine the localization of the 
weakness of structure and function, and the consequent distortion in 
one or other limited district of the spine, is probably but inadequately 
explained. Weakness of constitution, whether connected with rickets 
or not, is, in most cases, the source to which we look for explanation 
of distortions of the spine ; but it might rather be expected, that such 
a generally acting cause would determine an equal yielding through 
the whole length of the spine. Such an exception to the general rule 
did occur in the following case. In a female, sixteen years of age, 
of feeble health and slim person, a single lateral curve, of consider- 
able depth, with its convexity to the right, and including the whole 
length of the spine, had formed in the course of a few weeks. That 
the yielding of the spine was owing to the weakness of the structures 
which should firmly bind together its component pieces, was evident 
by the effect of such moderate extension of the column as could be 
made by gently elevating the head and shoulders, for then the cur- 
vature wholly disappeared. An apparatus was applied, for the object 
of keeping the vertebrae in their proper place ; and when this had 
been continuously worn for nine months, it was removed without the 
recurrence of the distortion ; and, besides, it was ascertained that the 
stature of the body now exceeded by two inches that which it was as- 
certained to be at the time of the first application of the apparatus. 
The increase may have been in part owing to growth, but it must have 
been chiefly owing to the straightening of the distorted spine. 

There are, however, considerations which guide the diagnosis be- 
tween the curvatures of the spine induced by rickets, and by other 
causes. The curvatures from rickets are rare among the children of 
the affluent. They occur equally in both sexes, whilst the curvatures 
from other causes are most frequent in females. Also, the curvatures 
from rickets occur at an earlier period of life than the curvatures oth- 
erwise induced, which appear usually in females, between the ages of 
ten and sixteen years. In these cases, moreover, the distortion is 
confined to the spine and ribs ; and is not, therefore, accompanied or 
followed by the distortion and defective growth in the pelvis and lower 
limbs, which are the characteristics of rickets. For the first notice of 
these important distinctions, we are indebted to Mr. A. Shaw, of the 
Middlesex Hospital, and to his late brother, Mr. John Shaw*. 

* On the Conformation of the Skeleton in Rickets, by Alexander Shaw, Esq, 
Medico-Chirurgical Transactions, Vol. xvii. 



RICKETS. 183 

Distortion in the form of the chest is a consequence of the curvature 
of the spine, and the distortion is often increased by the yielding of the 
softened ribs to the action of the muscles which are attached to them. 
The sides of the chest are, in most instances, flattened, and the sternum 
is thrust forwards ; but the softened ribs yield in various directions, 
and the form of the chest varies in different cases, in correspondence 
with the varieties in the curvature of the spine. 

The pelvis is small from the interruption of its growth, and remark- 
able changes occur in its form, from the yielding of its bones and liga- 
ments. The pressure which the heads of the thigh bones make through 
the acetabula, upon the front wall of the pelvis, is constantly tending 
to approximate it to the posterior wall, and besides to give the front 
wall the flattened form, which is characteristic of the rickety pelvis. 
The hollowness of the loins, which, also, is a character of rickets, is a 
consequence of changes in the position of the sacrum, produced 
by the weight of the spine and parts around, the head and up- 
per limbs, constantly bearing downwards upon the sacrum. The 
base of the sacrum is in consequence apparently thrust downwards 
and forwards, whereby its promontory is rendered unnaturally promi- 
nent, and its posterior surface forms the bottom of a hollow in the back 
part of the pelvis. But it is not to be understood, that in the rickety 
pelvis, the sacrum is thrust forwards in front of the ilia. The follow- 
ing are apparently the changes which here ensue. The yielding of the 
sacro-iliac symphyses permits a sort of movement of the sacrum in 
such a direction as make its promontory project forwards and its apex 
project backwards ; and, at the same time, the iliac bones are forced 
backwards in a direction to overlap the sacrum, and to approximate to- 
wards each other, in some instances to such a degree, that not more 
than the space of an inch has intervened between their posterior bor- 
ders. 

The following observations, communicated to me by Dr. A. Farre, 
complete the view of the changes which occur in the pelvis from rick- 
ets. " It is a circumstance of not infrequent occurrence, where the 
antero-posterior diameter of the brim of the pelvis is diminished by an 
unnatural approximation of the promontory of the sacrum to the sym- 
physis pubis, that the corresponding diameter of the outlet remains un- 
affected, or is even increased, partly by the tilting backwards of the 
other extremity of the sacrum, and partly by an unusual straightening 
of the bone, by which the hollow of the sacrum is nearly obliterated. 
Of this, there is a very good example in the museum of King's Col- 



184 RICKETS. 

lege. The conjugate diameter of the brim, in this case, measures only 
two inches, in consequence of the falling in of the promontory of the 
sacrum ; while the corresponding diameter of the outlet measures ex- 
actly the double of this ; the sacrum being, at the same time, so 
straight, that the hollow does not measure quite half an inch at its 
deepest point. In these cases, the bending appears to take place chief- 
ly in the iliac bones, which permit the sacrum to fall forwards. They 
form a striking contrast with those pelves, in which, the sacrum being 
much softened, becomes bent upon itself, the coccyx approaching the 
promontory, and the hollow of the sacrum being increased to a depth, 
in some instances, of two inches, while the antero-posterior diameter, 
both at the brim and outlet, are equally reduced." 

The necks of the thigh bones, yielding to the superincumbent weight, 
lose their obliquity ; they gradually approach to a horizontal direc- 
tion ; and the dropping of the heads and necks of the thigh bones, in 
some instances, takes place in such a degree, that the heads of the 
bones become situated below the summits of the great trochanters. 

Arrest of growth is a prominent character of rickety long bones ; 
they are of small dimensions ; this however is, in general, most mark- 
ed in the lower limbs : hence, the short stature of such, persons, inde- 
pendently of incurvations of their bones. In long bones, the defective 
growth in length is often such that they are not more than half their 
natural dimensions ; but in the direction of their thickness, it is not so 
constant : thus thigh-bones, a third, or even a fourth, shorter than nat- 
ural, are often of their natural thickness. Occasionally, other pheno- 
mena are observed in the rickety skeleton ; some of its bones are dis- 
torted, whilst others are of their natural figure and length, but, from 
the failure of growth in the direction of their thickness, are so slender 
as to present the characters of extreme atrophy. 

In the lower limbs, the weakness of system, which gives rise to cur- 
vatures in the bones, also occasions a yielding of the ligaments of the 
knee and ancle-joints ; hence the distortions of these joints, from the 
yielding of their ligaments become part of the phenomena of rickets. 
And there are instances of such distortions of the knee and ancle- 
joints, unaccompanied by any bending of the bones. 

It had long ago been observed, that deformity of the spine from 
rickets is generally accompanied by curvatures of the thigh bones. 



RICKETS. 



185 



And to this circumstance reference has been made, in illustration of a 
supposed law, determining the progressive ascent of the rickety chan- 
ges in the bones, from the lower to the higher parts of the skeleton ; 
accordingly, that the deformity of one part implies the deformity of 
the parts below it. Such, certainly, is the ordinary progress of rick- 
ets, but there are exceptions to it. In the museum of King's College, 
there is an adult skeleton, exhibiting distortion of the spine, and of the 
upper and lower limbs, but none of the pelvis ; and in another adult 
female skeleton, which I examined, there was extreme distortion of the 
spine, and of the lower limbs, with but the slightest change in the fig- 
ure of the pelvis*. Again, in opposition to any supposed law, regulat- 
ing the progressive changes of the bones in rickets, the instances may 
be noticed, in which only a single bone becomes distorted. A man, 
forty years of age, was admitted into St. Bartholomew's Hospital on 
account of disease in his urinary organs : his whole body was small, 
almost of dwarf-like size, and in the bones of both fore-arms, there had 
been such an interruption of growth, that each fore-arm was scarcely 
half its proper length in relation to the upper arm. But only a single 
bone had undergone any change in its figure ; this was the left tibia, 
which was considerably curved. 

There are observations which show, that the reason why the distor- 
tion from rickets first, and mostly, appears in the bones of the lower 
limbs is, that these bones are, more than any others, exercised in their 
functions, as organs of support and locomotion, at the age in which 
rickets usually commences ; consequently, that when softened by rick- 
ets, they first yield to the weight of the body, and to the action of the 
muscles which surround them. Upon this subject, Dr. A. Farre has 
communicated to me the following remarks : — " With regard to the ef- 
fects of rickets upon the upper extremities, I have seen these bent in 
cases where the lower extremities, and, indeed, the rest of the body 
generally, exhibited no signs of the disease." Having related the par- 
ticulars of two such cases, Dr. Farre observes : — " These two cases of 
rickety curvature in the upper extremities, when the lower remain un- 
affected, may be adduced to controvert the doctrine that rickets is a 

* In the museum of St. Bartholomew's Hospital there are ten specimens of curved 
spines preserved with the pelves. In six of these, the pelvis is distorted, in the other 
four, it is unaltered. In the same museum, there are three specimens of curved spines 
preserved with the pelves and lower limbs. In all these, the pelvis and limbs are dis- 
torted; in two of them, the distortion of the pelvis is considerable ; in the third, it is tri- 
fling, but the limbs are, in this instance, greatly distorted. 

16* 



186 RICKETS, 

disease, which always commences in the lower extremities, and pro- 
ceeds upwards. I rather look upon the deformities produced by rick- 
ets, as dependent in all cases upon mechanical causes, operating upon 
unhealthy osseous structures. And I explain the circumstance of the 
usual development of the disease in the lower extremities first, by ref- 
erence to the fact, that these have to sustain the weight of the body, 
and, consequently, yield, and become curved, before the upper extrem- 
ities exhibit any signs of their being affected by the softening process. 
Thus, it will be observed, that the cases which I have described, of 
rickety curvature affecting the upper extremities only, are cases of in- 
fants at the breast, who had not yet begun to use the lower extremities, 
and, consequently in whom, there had been no application of pressure 
to these parts, the deformity being shown, in these cases, in those ex- 
tremities only, which, in infants of that age, are the most employed, 
namely, the arms. In these cases, the deformity is still, I imagine, 
produced by a mechanical cause, namely, by muscular contraction. It 
is well known, that the power of grasp in the hand of an infant is of- 
ten very considerable ; the muscles employed for this purpose being 
those which lie on the inner side of the fore-arm. Now these being 
employed in infants more constantly perhaps than any other set of mus- 
cles, in their restless efforts to seize all objects within their reach, will, 
if the bones are soft, give a tendency to curvature in that direction in 
which traction is most frequently employed." In a third case, which 
Dr. Farre communicated to me, he had the opportunity of observing 
the curvatures taking place, first in the fore-arms, and afterwards in 
the legs ; the bones in this instance, from their softened condition, 
yielding to attacks of convulsion, which first affected chiefly the upper 
half of the body, and subsequently the lower, when the legs became 
bent. 

Perfect reparation of rickety bones would imply the recovery of 
their natural form and texture ; and this does, under favourable cir- 
cumstances, take place. In most instances, however, of considerable 
.distortion, the bones regain hardness of texture, but remain curved or 
twisted, and of proportionately small dimensions. 

The rickety bone recovers its hardness by the approximation and 
consolidation of its lamellae, but the interspaces of its cancelli remain 
wider than in healthy bone. A remarkable feature in the reparative 
process, is the deposit of so large a proportion of earthy matter in the 
soft bone, as to give it a hardness and weight much beyond that of 



RICKETS. 187 

healthy bone ; in some instances almost equal to that of ivory. Thus 
the hardness of the repaired rickety bone may compensate for the cur- 
vature of it, so unfavourable to the support of the weight it has to sus- 
tain. Other circumstances of interest arise in this process ; they are, 
the obliquity of the lamellae and fibres within the curved and hardened 
bone, also the greater thickness of its walls on the concave, than on 
the convex, side of its curvature ; and, besides, the remarkable pro- 
longation of the linea aspera of the femur, both in its breadth and 
thickness. These arrangements are certainly calculated to give 
strength to the bent bone in the direction where it is especially want- 
ed, and it is difficult to avoid the conclusion that this is their special 
purpose*. 

Long bones, especially the tibia and fibula, when bent into an angu- 
lar form, rarely regain their natural figure ; and the medullary tube 
becomes obliterated at the angle, so that the bone here consists only of 
compact tissue. The tibia and fibula, besides the curvature, occasion- 
ally become flattened, and of greatly increased width. Other peculi- 
arities occur in repaired rickety long bones ; their shape is, in some 
instances, irregular, especially near their articular ends ; and there are 
often osseous growths from them of the character of exostoses. 

Flat bones, affected by rickets, become, in the progress of repara- 
tion, hard, compact, and heavy, and, hi some instances, of greatly in- 
creased thickness. 

Short bones, of various figures, affected by rickets, become, in 
the progress of reparation, irregular on their outer surface, and hard 
in texture. 

Among the usually assigned causes of rickets, impure air and defec- 
tive nutriment are probably the most influential ; and in this view, the 
production of rickets might appear to be due to the operation of the 
same causes upon the animal system, as the production of tubercle in 
the lung, and elsewhere ; yet the existence of such an alliance be- 
tween these maladies, is not indicated by frequent simultaneous occur- 
rence in the same individual. In the examination of the bodies of 
twenty rickety children, tubercle in the lung was found in only six ; 
and it appeared that tubercle occurs less frequently in children who 
have died from rickets, than in those who have died from other dis- 

* Medico- Chirurgical Transactions, Vol. vii. Illustrations of the, Condition of the 
Bones in Rickets and of the Mode of their Reparation, Plate 20. 



188 RICKETS. 

eases* ; nor is rickets commonly accompanied by enlargement of the 
superficial absorbent glands, or other outward marks of scrofula. Ro= 
kitansky observes to the same effect, that rachitis and tubercle are 
very rarely associated ; that, particularly in the instances of rachitic 
malformation, with contraction of the chest, tubercle is scarcely ever 
found to exist. It does not appear, moreover, that in those who have 
recovered from rickets, the duration of life is shortened. In the mu- 
seum of the University of Boon, I saw the skeleton of a man who 
died at the age of seventy-seven, in which the long bones are curved 
and expanded at their extremities, and the flat bones are thickened. 
And in the same museum there is the skeleton of a female who died 
at the age of ninety-four, the bones in which are curved from 
rickets. 

TREATMENT OF RICKETS. 

Here it is deemed sufficient to state the principal indications of 
treatment arising from the consideration of the changes which the 
bones and joints suffer in rickets. 

In conjunction with general measures directed to the strengthening 
of the system, such local measures are to be directed to the weak and 
distorted structures as will add to the vigor of the circulation in them, 
and thereby improve their nutrition. Frictions of the part tend to 
this result ; but exercise of the muscles is the more decided means of 
its accomplishment. Free action of the muscles around the rickety 
bone is quickly, and with certainty, followed by increase of its strength, 
and this is no more than might be expected from the principle mani- 
fested throughout the animal kingdom, in the correspondence of 
the hardness of the bones with the energy of the muscles which 
clothe them. 

Increase of the distortion in the bones or joints is to be prevented ; 
and efforts are to be made for the removal of the existing distortion 
and deformity. For these objects, mechanical contrivances are availa- 
ble, with the best results. If, for instance, by the yielding of the lig- 
aments of the knee, or ancle, distortion of the joint has ensued, an 
apparatus is sought for, which will direct the joint to its right position, 
and maintain it so, whilst the weakened ligaments are recovering their 
tone. Much good is to be accomplished by moderate, but continuous 

* Eecherches sur le rachitisme chez des enfans, par M. Eufz. Encyclographie des 
Sciences Medicales 3 Mars, 1834. 



RICKETS. 189 

pressure directed against a bent bone, or distorted joint, for the object 
of regaining its right form and position. 

The employ of mechanical contrivances is clearly indicated, when 
the exercise of the part cannot be permitted without increase in the 
curvatures of the bones, or in the distortion of the joints which have 
yielded from the weakness of their ligaments. Without such aid, the 
rickety bone may recover its firmness, but it will retain its deformity ; 
and the ligaments of the distorted joint may recover their tone, but it 
will be with no less ening of the distortion. 

One condition essential to the proper use of all mechanical appara- 
tus, wherever applied, is, that neither by its weight, nor by the mode 
of its application, should it restrict the free action of the muscles of 
the part which is the seat of the distortion. In other words, the appa- 
ratus must be so constructed and applied, that it can be worn without 
hindrance to the natural movements of the part. And, besides, it is 
desirable, for the full effect of mechanical contrivances, that their ac- 
tion should be continuous, not remitting. Directly the restraint they 
impose is withdrawn, or even lessened, the muscles, aided by the con- 
tractility of the other tissues surrounding the distorted bone or joint, 
will begin to reproduce the distortion. And this evil tendency will 
continue long after the apparently perfect restoration of the part to its 
right form and position. 

There is, however, a limit to the capability of restoration in the rick- 
ety bone, or distorted joint. Although it be true, that the bone which 
is bent, and even in a great degree from the softness of its texture, can 
be made to regain its natural figure ; yet, when the altered form of a 
bone is such as to imply something beyond mere mechanical agency, it 
is to be expected that the distortion will be permanent — such, for ex- 
ample, as the thinning of the bodies of the vertebras, from the pres- 
sure they have suffered, or, from the same cause, the altered form of 
the articular ends of the bones of a distorted joint, for these changes 
are the result of a vital action in the part ; and "there is no evidence 
to prove that a bone thus altered, can be remodelled into its natural 
form and proportions. Accordingly, the curvatures of the rickety 
spine will be permanent, when accompanied by thinning of the bodies 
of the vertebras ; and the distortion of a joint will be permanent, when 
accompanied by change in the configuration of its bones. 



CHAPTER II 



CONDITIONS OF BONE DESIGNATED MOLLITIES, AND 
FRAGILITAS OSSIUM*. 

These terms are applied to certain conditions of bone, characterized 
by either a softening or brittleness of its tissue ; but it is doubtful 
whether they are actually distinct diseases. The pathology of these 
affections is indeed so little understood, that in treating of them, I 
purpose merely to arrange the cases which they include conveniently 
for reference and illustration. 

In this series of cases, the walls of the bones become thinned, and, 
in some instances, softened ; their medullary tubes and cells are found 
filled with fatty matter, not materially differing in its characters from 
healthy medulla. Such being one of the conditions of the osseous 
system belonging to advanced age, it becomes a question, whether some 
of the recorded examples of mollities and fragilitas ossium were not 
instances of the simple atrophy of the bones, occurring in old persons. 
There have, however, been cases in which similar changes in the 
osseous system occurred in the middle period of life, accompanied by 
peculiar constitutional symptoms, and terminating fatally. The fol- 
lowing is the history of such a disease. 

In a female, twenty-five years of age, the first symptom of disorder 
was a sense of weariness, succeeded by severe pains in the limbs. The 
pains were referred to the bones, and gradually increasing in severity, 
she died worn out by suffering, eighteen months after the commence- 
ment of the malady. Four clays before death, whilst turning in bed, 
the left femur broke in its middle third. All the bones were found of 

* The terms osteo-malacia and malacosteon, have also been applied to these affections 
of bone. 



MOLLITIES, FBAGILITAS OSSIUM. 191 

their natural form and size, but very light, and by the slightest effort, 
any of them could be broken. The periosteum could be separated 
from every bone with unusual facility. The surface of each bone was 
of a deep red colour, and its texture was so soft, that it could be 
readily penetrated by a scalpel. The walls of the long bones were 
reduced to the thinness of a line, with enlargement of their medullary 
tubes and cells, which were filled with a very thick, deep red medullary 
substance. The medullary membrane was thickened*. 

Other cases, similar to the foregoing, are recorded, and they have 
occurred chiefly in females. The morbid changes in the bones were in 
general preceded by severe pains in them, which were supposed to be 
rheumatic, and were accompanied by extreme debility of the system. 
In some instances, there was haemorrhage from the gums, with other 
symptoms of scurvy! . After the continuance of the pains in the 
bones, and the constitutional derangement for some time, the nature of 
the disease has in general been made evident by the bending of one 
or more of the bones upon some slight effort. In one case, during the 
progress of the disease, a white sediment was deposited from the urine, 
which, upon evaporation, became, it is stated, like mortar |. In a 
second instance, this sediment was ascertained to be the earthy matter 
of the bones§. In the history of another case, it is stated, that abun- 
dance of chalky matter was found in the urine ||. And in a case re- 
corded by Mr. Solly, the urine contained between three and four 
times the amount of phosphate of lime that belongs to it in health^ . 
There is, however, one other case recorded, in which nothing different 
from health could be discovered in either the perspiration or the urine**. 

In most of these cases, the disease attacked the whole skeleton ; in 
a few, only the spine and pelvis ; and in some, only a single bone. 
In nearly all the cases where the contents of the widened medullary 
tube and cells were carefully examined, they were found to consist 
only of adipose matter, which, by long maceration, could be converted 
into adipocire. In the -museum of Dr. Hunter, at Glasgow, I saw 

* Observation de maladie generate des os, par M. Robertz. Encyclographie des 
Sciences Medicales, Aout, 1834. 

t Case by Sir Jolm Pringle, Philosophical Transactions, Vol xlviii. 
I Case by Mr. Thompson, Medical Observations and Enquiries, Yol. v. 
§ Case by Mr. Bromfield, Chirurgical Observations, Vol. ii. 
|| Case by Dr. Hosty, Philosophical Transactions, Vol. xlviii, 
IT Medico- Chirurgical Transactions, Vol. xxvii. 
** London Medical Journal, Vol. vi. 



192 

several of the bones which were obtained from the case recorded by 
Mr. Thompson. Their walls and cancellous texture had wholly disap- 
peared ; their periosteum was much thickened, and enclosed a yellow 
adipose substance. In a case described by Mr. Hunter*, and of which 
specimens are in the museum of the College of Surgeons, he says, the 
bone " resembled a species of fatty tumor, giving the appearance of a 
spongy bone, deprived of its earth and soaked in soft fat." 

In a portion of the femur, recently examined by Mr. Paget, from a 
case of softening of the bones, which was under the observation of Mr. 
Tamplin, the medullary tube and cells were filled with a substance 
presenting the appearance of variously coloured jelly ; yet it. contained 
a large quantity of fluid oil, not lodged in fat cells, but held in its 
place by the remnants of the medullary membrane. The osseous tis- 
sue itself contained a praeternaturalis large quantity of oily matter. 
In a case recorded by Mr. Howship, the walls of the long bones had 
wholly disappeared, and the contents of the periosteal tube are stated 
to have been " a red pulpy or fleshy matter, in some parts resembling 
liver — in others, grumous bloody." But portions of the bones from 
this case, preserved in the museum of the College of Surgeons, show 
that a large part, or nearly the whole, of this peculiar substance con- 
sisted of fat. 

Dr. Bostock furnished me the following analysis of a portion of the 
femur, from the case recorded by Mr. Curlingf : " On the first in- 
spection, it appeared to be composed of an homogeneous mass of adi- 
pose matter, enclosed in a thin bony shell. The adipose matter was of 
a light brown colour, and had the appearance and constitution of but- 
ter. Upon a more minute examination, the interior of the bone was 
found to consist of a very delicate cellular texture, the cavities of 
which were filled with a fluid oil, which was so abundant as to give to 
the whole the homogeneous appearance described above. A piece of 
the bone was placed on an inclined plane of glass, and a considerable 
quantity of a fluid spontaneously oozed from it, which had the consis- 

* Observations on the case by Mr. Goodwin, in the London Medical Journal, Vol. vi. 

t Transactions of the Medico -Chirurgical Society of Edinburgh, Vol. ii. 

} Museum of St. Bartholomew's Hospital, First series, Nos. 129, 130. Specimens of 
the bones from the case described by Mr. Curling, Medico- Chirurgical Transactions, 
Vol. xx. One of these is the section of a femur, the walls of which are very thin and 
soft, and the widened medullary tube is filled by a yellow adipose substance, resembling 
lard. Another is the section of a humerus, in which the adipose substance, by long 
maceration in water, has become firm, and of a Avhite colour, resembling adipocire. 



FRAGILITAS OSSIUM. 193 

tence, physical properties, and general appearance of spermaceti oil. 
The constitution of the entire bone was, 100 parts — of oil, about 67 ; 
of membrane, about 20 ; of earthy salts, about 11. The composition 
of the earthy salts was, in 100 parts — phosphate of lime, 90 ; carbo- 
nate of lime, about 8; sulphate of lime, about 2. The obvious pecu- 
liarity of this bone, was the very large quantity of oil it contained, 
amounting probably to three-fourths or more of its whole weight, and 
the corresponding small quantity of membranous basis and earthy salts. 
The appearance of the bone, both after the oil had drained off, and 
after calcination, indicated rather a mere deficiency of the solid parts,, 
than any thing that resembled disease." 

Sufficient evidence has been adduced to prove the occurrence of a. 
peculiar constitutional affection, accompanied by softening of the bones,, 
with thinning of their walls, and with the accumulation of adipose- 
matter in their tubes and cells. This disease, occurring in the middle? 
period of life, has in general terminated fatally in one or two years-,, 
and, in most of its instances, it presented the remarkable feature- 
of a preternatural excretion of phosphate of lime with the urine. 

The softened tissue of the bones, in the cases which have been con- 
sidered to constitute the disease designated mollities ossium, is followed 
by the distortion of them. It is unnecessary to describe the particular 
directions in which the bones yield, for, indeed, they bend in all di- 
rections likely to be determined by the muscles acting on them, and 
by the weight they sustain. Between the distortions from mollities 
ossium, and from rickets, there is just this difference, that the former 
occur after the growth of the bones is completed, whilst the latter 
occur in early life ; hence the dwarfish size, from the arrest of growth, 
in the bent rickety bones ; hence, also, the unnatural shapes into 
which they become modelled. The distinctive features of mollities 
ossium and of rickets are strongly marked in the pelvis. A chief char- 
acter of the pelvis, altered by mollities ossium, is the pushing inwards 
of its sides by the pressure of the heads of the thigh bones against 
the acetabula, which is so remarkably contrasted with the flattening 
of the front wall in the rickety pelvis. It has been well observed, that 
if, in mollities ossium, the various doublings of the distorted pelvis 
could be unfolded, it would be restored to its natural form and propor- 
tions ; not so with respect to the rickety pelvis, where, with the yield- 
ing of the bones and ligaments, the parts are of dwarfish size, and of 
undue shapes and proportions, from the unnatural modelling they have 
undergone during the growth of the body.. 
IT 



194 MOLLITIES, 

Various cases have been included in the series comprised under the 
head of fragilitas ossium, which certainly do not belong to it ; as, for 
example, the carcinomatous and encephaloid deposits in bones, accom- 
panied by the removal of their inner laminae and cancellous texture. 
There are, however, instances of the simple thinning of the walls of 
bones, unaccompanied by morbid deposit in their interior, or by soften- 
ing of their texture. In some of these, rheumatism, and in others, 
syphilis, preceded the manifestation of disease in the bones, by the 
occurrence of fracture in one or more of them. Also, in the advanced 
stages of carcinoma, especially in the breast, thinning of the walls of 
the long bones, and fractures of them from apparently slight causes, 
are especially observed. In many instances, a fixed pain in the bone 
has preceded its fracture. In some cases, only a single bone has been 
fractured ; but in others, there have been fractures of several bones 
occurring in quick succession. In a case recorded by Mr. Tyrrell, 
there had been as many as twenty-two fractures, scarcely a long bone 
having escaped* ; and in another case, recorded by Mr. Arnott, there 
had been thirty-one fracturesf . 

It is remarkable, that the fractures which occur in these cases, are 
generally accompanied by very little pain, and are followed by scarcely 
any inflammation in the part ; it is still more remarkable, that notwith- 
standing the unsoundness of the bone preceding its fracture, the union 
of it should take place in the ordinary period, and occasionally within 
it. I have seen many instances in proof of this statement. The fol- 
lowing is one of them. In a female, aged thirty, whilst she was rais- 
ing a light chair, the humerus broke in its middle. During the pre- 
ceding year, she had been under treatment for secondary syphilis, and, 
for several months, had suffered severe pain in the part of the bone 
where the fracture now occurred. As the bone was supposed to be un- 
sound, it was presumed the reparation of the fracture would be tedi- 
ous, perhaps wholly fail — but it proved otherwise. At the end of a 
month, the union of the fracture was moderately firm ; in five weeks it 
was perfectly so. Mr. Tyrrell observes, in reference to the case he 
related, that " in the man who had had so many fractures, the acci- 
dents were repaired with greater rapidity than I have seen in other in- 
dividuals, the union of the fracture of the femur being perfectly firm 
at the expiration of three or four weeks." In a female, aged fourteen, 
under the care of Mr. Arnott, in Middlesex Hospital, the first fracture 

* St. Thomas's Hospital Eeports, No. 1. 
f Medical Gazette, June, 1833. 



FRAGILITAS OSSIUM. 195 

occurred at the age of three* years ; altogether there were thirty-one 
fractures in different bones 3 and in some of them the fracture was many 
times repeated. Many of the fractures occurred from the slightest ef- 
fort, and there was no difficulty in obtaining their union. In a sister 
of this patient, six years of age, there was the same condition of the 
bones, favouring the occurrence of fractures. She had suffered nine 
fractures since the age of eight months. A case, similar to the fore- 
going, was under the care of Mr. Earle, in St. Bartholomew's Hospi- 
tal. A boy, aged ten years, had suffered eight fractures, six in one 
tibia, and two in the femur. Each fracture of the tibia occurred in a 
different part of the bone, and had united within the usual period. 

In one of the cases just related, the disposition of the bones to 
break from very slight causes, was manifested in two members of the 
same family. In other instances there has been a still more decided 
hereditary tendency to such an affection of the osseous system. Dr. 
Pauli, of Leipzig, states, that he is acquainted with a family, in which 
individuals, belonging to three generations, have suffered from extraor- 
dinary fragility of the bones*. 

The following cases will illustrate the various circumstances attend- 
ant on this condition of the osseous system. 

Fractures of the Humerus and Femora, following Rheumatism. 
The following case was communicated to me by Mr. Wilson, surgeon to 
the Manchester Infirmary. A female, twenty-four years of age, was 
admitted into the Infirmary, in the supposition that she was suffering 
from rheumatism. As she was being carried up the staircase, the shaft 
of her left femur broke, and it was ascertained that nine months previ- 
ously, she had suffered a fracture of the left arm, in catching hold of 
a balustrade ; this fracture had united, and the union of the fracture 
of the femur was also in progress, when, as the patient was being rais- 
ed in bed, she felt a severe pain in the opposite thigh, and exclaimed 
that the bone had broken, which was found to be true. Erom this pe- 
riod, her health rapidly declined ; she complained of aching in her 
bones, and of general weariness, with failure of appetite. Every ef- 
fort Avas made to sustain the vital powers, but without effect ; she died 
about four months after her admission into the Infirmary. A portion 
of the recently fractured femur exhibits a thinning of its walls, from 
the absorption of its inner laminee, but without softening of its texture 
— it retains the hardness of healthy bonef. 

* Untersuchungen und Erfahrungen im Gebiete der Chirurgie. 
t Museum of St. Bartholomew's Hospital, First series, No. 128. 



196 

Several Fractures in the Bones of the Lower Limbs, of which no 
union could be obtained. A female, aged twenty-six, was admitted 
into St. Bartholomew's Hospital, with a fracture in the upper part of 
the shaft of the left femur. She stated, that she had suffered rheuma- 
tism in this limh, and that, three days previously, the fracture occurred 
as she was crossing a road. She was placed on her back, with a 
straight splint on the outside of the limb. When she had been in the 
hospital about two months, whilst lying perfectly quiet in bed, she sud- 
denly cried out that she felt a severe pain in the other thigh, and that 
the bone had broken ; the house surgeon, happening to be in the ward, 
found the right femur fractured in its centre. At subsequent, and dis- 
tant periods, whilst confined in bed, a second fracture of the left femur, 
occurred, a little above the knee, and fractures of both tibiae, immedi- 
ately below their tuberosities. She remained in the hospital above two 
years, during which, every effort was made to obtain the union of the 
fractures. Throughout, her general health was unimpaired, the appe- 
tite good, bowels regular, and the urine perfectly natural. The most 
generous diet and tonic medicines were freely administered. Having 
found in a German journal, an account of cases of ununited fracture 
successfully treated, by giving to the patients lime and phosphoric 
acid, I administered, in this case, these medicines, in the following pro- 
portions — first, fifteen minims of the dilute acid in an ounce of lime- 
water, afterwards thirty minims of the acid in an ounce and a half of 
lime-water every six hours, and this treatment was continued for three 
months, but without benefit. At the expiration of two years, from the 
occurrence of the first fracture, the patient left the hospital, both low- 
er limbs being powerless, and when moved, severely painful. None of 
the fractures had united, and both limbs were shortened to the extent 
of several inches, with considerable distortion. 

Thinning of the Walls of all the Bones of a Lower Limh, in a 
young person, unaccompanied by constitutional derangement. A boy, 
fifteen years of age, was admitted into St. Bartholomew's Hospital, 
under the care of Mr. Lawrence, on account of disease in his knee- 
joint. The disease had existed for fifteen months, and its symptoms 
were those of inflammation in the synovial membrane, leading to the 
destruction of the articular cartilages. Four years and a quarter be- 
fore the disease of the knee began, he had been laid up for thirteen 
months, with disease of the ancle in the same limb. But he apparent 
ly quite recovered from this affection, and he thought his right (dis- 



FRAGILITAS OSSIUM. 197 

eased) limb was as large and as strong as the other, until the affection 
of the knee commenced. 

In the amputation of the limb, a single stroke of the saw cut through 
half the femur, and the remainder broke, the bone was so small 
and its walls so thin. All the other tissues of the limb appeared 
healthy. 

The knee-joint exhibited the ordinary changes of structure, from 
inflammation of the synovial membrane and ulceration of the car- 
tilages. The femur, and the bones of the leg and foot, were of 
small size, their walls were extremely thin, and their cells filled with 
adipose matter. 

The wound of the operation healed soundly, and within the usual 
period. 

The foregoing histories prove the occurrence of cases wherein there 
is a simple thinning of the walls of a single bone, or of many bones, 
unconnected with other morbid change, accompanied, in some instan- 
ces, by derangement of the health — in others, not so — occasionally ap- 
pearing as a symptom of secondary syphilis, and often arising as a 
consequence of the peculiar state of the system, attendant on the ad- 
vanced stages of carcinoma. Still, however, it is not clear, that this 
condition of the bones disposing them to fracture from the slightest 
causes, is a different disease from that which was previously described, 
wherein the thinning of the walls was accompanied by softening of the 
texture of the bones, disposing them to bend rather than break ; since, 
between these two states of the osseous system, there is really no other 
observable difference than in the relative proportions of the animal and 
earthy constituents of the affected bones — their chemical constitution is 
apparently the same. 

Probably, the correct view of the changes occurring in the osseous 
system, through the whole series of cases included in this section, is, 
that they consist in a process of wasting or atrophy of the bones, de- 
termining, in some cases, a large removal of their earthy constituents, 
and in others, of their animal constituents, and so disposing them to 
bend or break, from the application of the slightest force. Although 
this wasting of the bones resembles in its characters the atrophy of 
them in old age, yet it does occur as a diseased affection, at all periods 
of life, and, as we have seen, often ends fatally. Our ignorance of the 
pathology of this affection must be acknowledged ; and, whilst this 

17* 



198 MOLLITIES, FRAGILITAS OSSIUM. • 

continues, it is to be expected that we shall remain, as we are at pres- 
ent, wholly ignorant of any curative measures, whereby such disease 
may be averted, or its progress arrested. Mr. Curling has adopted 
similar views of these conditions of the osseous system, in his Essay on 
" Some of the Forms of Atrophy of Bone*." 

Medico-Chirurgical Transactions, Vol. xx. 



CHAPTER III 



SCROFULA IN BONE. 



It has appeared to me, that the bones are primarily affected in only a 
proportion of the scrofulous disease of joints. I cannot doubt the 
occurrence of two other forms of scrofulous disease in joints preceding, 
or independent of, the scrofulous disease of the bones, — one originating 
in inflammation of the synovial membrane, the other in inflammation 
of the cellular tissue around the joint. Acknowledging the uncertainty 
there may be in the definition of scrofulous disease, I desire simply to 
state, that I have watched the progress and termination of diseased 
hip-and knee-joints, which had exhibited the well-marked local and con- 
stitutional characters of scrofula : yet, upon examination, inflammation 
was found in the synovial membrane, with tuberculous deposit in the 
joint and around it, or there were scrofulous abscesses around the 
joint ; whilst in the bones no unsoundness existed. 

Our best observations of the incipient effects of scrofula in bone, 
are made in joints not covered by much thickness of soft tissues. 
Here, the increased heat, tenderness, and slight swelling of the bones, 
denote the existence of inflammation in them, occasioning increase of 
their vascularity, with the enlargement of them by expansion of their 
texture. In the elbow,- and in the ancle-joint, when recently attacked 
by scrofulous inflammation in the bones, the hand grasping the joint, 
will readily recognize the greater heat in its bones than in the soft 
parts around them. When an examination is made of scrofulous bones 
in this early stage of disease, they are found expanded and congested, 
the medulla in their cells being mixed with blood. How long this 
stage of scrofulous disease in bone will endure, cannot be definitely 
stated. It is, however, certain, that it may continue many months ; 
for, in instances where disease in a joint had so long continued, with 



200 SCROFULA IN BONE. 

all the features of scrofula, yet, on examining the joint, no other mor- 
bid changes were found in it, than the simple inflammatory condition 
of its bones. 

The change in scrofulous bone, next in the order of occurrence, is 
the disappearance of its earthy matter, which is often so complete, that 
the bone becomes readily compressible by the fingers. Then, the de- 
posit of tuberculous matter into it ensues, either in a circumscribed 
cavity, hollowed out of the bone, or diffusedly through its cells ; and, 
in some instances, also between the periosteum and the bone. The 
following analysis of a scrofulous bone in this stage of its disease, was 
furnished me by Dr. Bostock: " The circumstances in which this bone 
differed from the healthy condition of bone are — first, in the small pro- 
portion of its earthy matter, and more especially in the entire absence 
of the carbonate of lime : secondly, in the presence of an unusually 
large proportion of oil or fat, nearly equal in amount to the gelatinous 
basis of bone : thirdly, in the mechanical condition of the albumen, 
which appeared to have its ordinary structure nearly destroyed, and to 
be, the whole, or a considerable part of it, in a disorganized state*." 

At the stage of tuberculous deposit in scrofulous bone, active in- 
flammation, quickly passing into suppuration, is very apt to arise in 
it, as the effect, either of constitutional derangement, or of local inju- 
ry ; and, moreover, it constantly happens, that the smallest amount of 
irritation, however excited, and often arising without apparent cause, 
at this stage of the disease, is directly followed by suppuration, and its 
consequent processes of disorganization in the bone. For then, the 
walls of the bone ulcerate, affording outlet to the purulent fluid ; and, 
with it, the tuberculous substance, and pieces of the diseased cancel- 
lous texture are discharged through the abscesses and ulcerated pas- 
sages in the soft parts around the diseased bone, these constituting the 
chief phenomena of scrofulous caries. 

To what extent is scrofulous disease in bone curable in the fullest 
•sense, implying the perfect recovery of its healthy properties and 
i structure ? My reply to this question would be, that the disease is 
perfectly curable only in its first stage, when the changes in the bone 
have not passed beyond those of simple inflammation. That the dis- 
ease is so far curable I have no doubt, from the observation of cases, 
chiefly in the knee, ancle, and tarsus, wherein, the expansion of the 

* Illustration of scrofulous bone, exhibiting the diffusion of tuberculous matter 
through its soft cancellous texture, Plate 18, fig. 1. 



SCROFULA IN BONE. 201 

bones, -with the long-enduring heat and tenderness in them, had as- 
sured me of the character of the disease ; jet, a considerable time af- 
terwards, a year, and often two years, in conjunction with the most 
marked improvement in the general health, all signs of unsoundness in 
the bones that had been diseased, had wholly disappeared. 

But when scrofulous disease in bone has reached the stage of tu- 
berculous deposit, with an exception presently to be noticed, no other 
result is to be looked for than the destruction of part, or the whole, of 
the diseased bone. The tuberculous matter excites suppuration in the 
surrounding osseous tissue, just as tubercle in lung, or in absorbent 
gland, gives rise to abscess in the healthy tissue around it, leading to 
the ejection of the tuberculous matter from the part in which it was 
deposited. The exception just noticed, is but another analogy between 
the diseased processes in lung, or in absorbent gland, and in bone ; for 
in the same way that tubercle in lung, or in absorbent gland, instead 
of exciting inflammation in the adjacent healthy tissue, may itself be- 
come changed into an earthy concretion, so does it appear, from good 
observation, that tuberculous matter in the cells of bone may become 
changed into a mass of earthy, or chalk-like substance. I had noticed 
the existence of masses of chalk-like substance in the cancellous texture 
of bones ; but I did not interpret this morbid appearance in the way 
that Rokitansky has, I believe, correctly done, by regarding the chalk- 
like substance as the result of metamorphosis of tubercle in bone, anal- 
ogous to the change it undergoes in other organs and tissues*. 

Even the most disorganizing and destructive processes of scrofula in 
bone, are of slow progress, and unaccompanied by the inflammatory 
changes in the periosteum, which, in other diseases of bone, are follow- 
ed by osseous deposits on its surface. 

No reproductive process ever ensues upon the destruction of bone 
by scrofulous disease ; hence, in the instances of its occurrence in the 
bone of a finger, shortening of the finger must be the permanent result, 
proportionate to the extent of bone that has been destroyed. 

How frequently, and under what circumstances, tubercle in bone 
co-exists with its deposit in the lungs, is a question of interest in refer- 
ence to the measure of removing a limb, when, upon good grounds, the 
opinion has been formed that disease, in one or more of its joints, com- 
menced in scrofulous changes within the articular ends of the bones. 
The evidence which can be offered on this subject does not amount to 
more than the few following isolated facts. 

* Pathologische Anatomie, Vol. i. p. 214. 



202 SCROFULA IN BONE. 

" A man, twenty years of age, suffered from the symptoms of pul- 
monary phthisis, during which he received a severe blow upon his leg. 
In the examination of his body, tubercles were found in the lungs, also 
in the cervical, axillary, and mesenteric glands. At the part where 
the leg had been injured, the periosteum was found separated from the 
tibia, and there was here a round cavity in the bone, the size of a hazel- 
nut, filled by a yellowish white substance, which, at its circumference, 
was solid, and could be crumbled in the fingers like curd." 

" In the body of a man, forty years of age, tubercles were found in 
the lungs, also in the bodies of the vertebrse, and in the sacrum*." I 
find no mention of tubercle in bone by Louis in his account of the pa- 
thological anatomy of phthisisf, but it does not appear that he extend- 
ed his inquiries into the condition of the osseous system. Even where 
there had been disease in a joint co-existing with phthisis which destroy- 
ed the patient, no mention is made of the condition of the bones ; 
from which it may be inferred that they were not examined. From my 
own observation I can only state, that whilst in some instances I have 
found tubercle in the lungs co-existing with tubercle in the bones, in 
others, where tuberculous deposit had taken place in the bones of a 
diseased joint, yet the lungs were sound. But the record which I pos- 
sess of cases bearing on this subject is insufficient for any conclusion 
respecting it. 

It is well ascertained that tubercle is occasionally deposited in the 
bones of more than one joint at the same time. But more frequently, 
when tuberculous deposit is found in the bones of one joint, the prima- 
ry changes from scrofula, not yet advanced to the tuberculous stage, 
are found in other bones ; thus, for instance, in a limb removed on ac- 
count of disease in the knee-joint, accompanied by tuberculous deposit 
in its bones, the bones of the ancle-joint are often found softened, slight- 
ly expanded, with their cancellous texture excessively vascular, and its 
cells filled by a serous and bloody fluid. 

TREATMENT OF SCROFULA IN BONE. 

No confidence can be held in local depletion as the means of remov- 
ing the local inflammatory symptoms of incipient scrofulous disease in 
bone, and, consequently, of arresting its progress. The leeches or 
cupping, applied to a joint, in the bones, of which, scrofulous disease 

* Andral. Clinique Medicale, Part III. Chap, iii, Section v. 
t Recherckes Anatomico-Pathologiques sur la Phthisie. 



SCROFULA IN BONE. 203 

has commenced, will, it is true, lessen the tenderness and morbid heat 
in the part, but these symptoms will quickly return ; nor will they 
yield to the repetition of the depletory treatment, which is moreover 
objectionable, from its tendency to weaken the system, and by so much, 
to lessen the constitutional powers of curing a disease, the essence of 
which, in respect to its cause, is debility. Nor will counter-irritation 
have a curative effect upon scrofulous disease of bone in its more ad- 
vanced stages. Such are my convictions from observation, of the ef- 
fects of depletory and counter-irritating measures directed to various 
bones affected by scrofulous disease. This, however, is a point which 
the observations of Sir B. Brodie had already well established*. Also, 
with respect to stimulating applications, in any degree of strength, and 
in any of their various forms, made to the soft parts covering scrofu- 
lous bone, my belief is, that their only certain effect, is that of rousing 
into activity, inflammatory processes in the diseased bone, tending to 
its disorganization and destruction. 

When scrofulous disease is seated in the articular portions of bones, 
motion of the joint, and pressure of the articular surfaces against each 
other, ought to be prevented, for either of these will be likely to give 
rise to suppuration within the bones, and ulceration of the cartilages, 
with abscess in the adjacent soft parts. By the application of suitable 
apparatus, such as the splints constructed of prepared leather, or of 
gutta percha, these objects can be attained, and in a way not to inter- 
fere with the freest exercise of the body, which, in conjunction with its 
exposure to fresh air, especially at the sea-sicle, are the chief, indeed, 
I am disposed to say, the only, remedial measures deserving confi- 
dence, for the cure of scrofulous disease in bone. Accordingly, in the 
instances which are so frequent, of scrofulous disease attacking the 
tarsus or ancle, the patient has to submit to the inconvenience of 
taking exercise with his knee bent upon a wooden leg, as the means 
of relieving from pressure and motion, the articular surfaces of the 
diseased bones. 

All other remedies for arresting scrofulous disease in bone, are, as 
it has appeared to me, but secondary and subordinate to the influence 
of sea-air. With respect to iodine and iodide of potassium, I have but 
to express the doubt I entertain of their beneficial effects in these 
cases. Not so with respect to the preparations of steel, and besides 
to cod-liver oil, which are beneficial, as the means of increasing appe- 

* On Diseases of the Joints. Edit. 4. 



204 SCROFULA IN BONE. 

tite, and improving nutrition. But even of these remedies, the impres- 
sion I have of the amount of good they are capable of doing, is not 
such as to induce me to rely upon them exclusively. In hospital prac- 
tice, the degree of power which these remedies have of arresting scro- 
fulous disease in bone is clearly shown, and I would not say more of 
them, than that they keep the disease in a quiescent state. But when 
the position of the patient is such, that exercise and the constant ex- 
posure to fresh air, especially at the sea-side, are the available means 
of imparting to his system the vigor which is requisite for the repara- 
tive processes in bone, then may it be expected that the diseased parts 
will slowly regain their healthy condition, without the aid of the other 
measures that have been regarded as of secondary and subordinate im- 
portance. 

One further consideration belongs to the treatment of scrofulous dis- 
ease in bone ; this is, the length of time required for its cure. Defi- 
nite statement will here scarcely be looked for : it may be so far ap- 
proached, that a shorter period than two years cannot be specified as 
the time required for the cure of the scrofulous bones of a knee, ancle, 
or tarsus. And here is the point of practical caution — that if the ar- 
ticular surfaces adjacent to the diseased bones are subjected to motion 
and pressure before the bones have regained their solidity and firm- 
ness, it will be done at the risk of exciting in them inflammatory pro- 
cesses leading to their disorganization and destruction. 



CHAPTER IV 



HARD CARCINOMA, AND MELANOSIS IN BONE. 

HARD CARCINOMA IN BONE. 

There are instances of a deposit in bone identical with the hard 
cancer in the female breast. 

I know of no instance of hard cancer in bone, where it occurred as 
a primary disease ; and I know of no case where the primary cancer 
was situated elsewhere than in the mammary gland, and I should have 
added of the female, but for the remarkable case presently to be re- 
lated, where the primary cancer occurred in the mammary gland of 
the male. 

The carcinomatous deposit has been found in bones of various forms ; 
in the medullary tissue of long bones, and in the cancellous texture of 
flat, and other-shaped bones. In the instances which I have seen, there 
did not appear to have been any change of structure in the bone, pre- 
ceding the deposit of the carcinomatous substance. This deposit takes 
place in the form of minute, round granules, which, as they increase, 
coalesce into a solid firm mass, of a light greyish-blue color, apparently 
homogeneous in its composition, without intersecting fibrous bands, and, 
of course, without the white streaks produced in carcinoma of the mam- 
mary gland by obstruction, or other change in the lactiferous tubes. 
The carcinomatous granules coalesce, either into separate masses, or 
into one continuous mass, extending widely through the bone, thus giv- 
ing rise to the alleged varieties of circumscribed or tuberous, diffuse 
or infiltrated, cancer in bone. In the case which will be presently re- 
lated, many of these varieties were observed ; thus, in the sternum, 
the carcinomatous substance pervaded the cancellous texture through- 
out, whilst, in the humerus, minute carcinomatous granules were scat- 
tered through the unaltered medulla, and at one part they had coalesc- 

18 



206 

ed into a tumor the size of a walnut, which had caused the absorp- 
tion of the adjacent walls of the bone. 

The changes which ensue in a bone, the seat of cancer, are the ab- 
sorption of its cancellous texture and walls, as the carcinomatous sub- 
stance gradually extends from the interior to the outside of the bone. 
Thus, as the disease advances, the walls of the bone become gradually 
thinner at the seat of it, and in most instances, they suddenly yield on 
the occasion of some slight effort, or movement of the limb, just as 
spontaneous fractures occur in the instances of thinning of the walls of 
bones from atrophy or disease, unaccompanied by morbid deposit in 
their interior. 

Whilst, in some instances, the carcinomatous substance has been de- 
posited to the extent of filling the entire medullary and cancellous tex- 
ture of a bone, and has, besides, penetrated its walls, in no case with 
which I am acquainted, has the carcinomatous substance extended so 
far beyond the walls of the bone, as to form a tumor projecting from 
it, in the manner of other morbid growths. 

In several instances, as in the case presently to be related, in con- 
junction with carcinoma in bone, carcinomatous deposits were also 
found in the lungs, showing the formation of this disease in the osseous 
system, to be connected with the general diathesis, leading to its depos- 
it in one or other organ, determinable by circumstances of which we 
have no knowledge. And in correspondence with this view of the sub- 
ject, is the fact already noticed, of there being no diseased action in 
the bone previous to the deposit of the carcinomatous substance, 
which, consequently, in the early stage of the disease, is found scatter- 
ed through the unaltered medullary and cancellous tiss ue 

In illustration of the foregoing history of carcinoma in bone, the fol- 
lowing case is related, which presents all the striking features of the 
disease ; and is besides of interest, from the circumstance of the dis- 
ease being here consequent on the occurrence of carcinoma in the mam- 
mary gland of the male. 

A man, forty-five years of age, of temperate habits, by occupation a 
butcher, was admitted into St. Bartholomew's Hospital, with the fol- 
lowing history of his disease, — that his general health, until very late- 
ly, had been good ; that about nine months ago, he first perceived a 
small hard lump close to the nipple of the right breast, which slowly 
increased without pain ; and that about three months ago the tumor ul- 
cerated in its centre. The tumor was about the size of half an egg, 
circumscribed, of a roundish form, very firm, closely adherent to the 



AND MELANOSIS IN BONE. 207 

skin, but loosely united to the cellular tissue behind it, upon which, 
therefore, the tumor was freely movable. In the axilla there was a 
mass of enlarged and indurated absorbent glands. About four months 
ago, he began to feel a shooting pain in the lower part of the right 
arm, which increased, with thickening of the tissues immediately 
around the bone ; and a few days after his admission, it was discover- 
ed that the humerus had here given way. About the same time, he 
began to complain of pain in his back ; also, of coldness and numb- 
ness, and of the failure of the power of motion in his lower limbs. A 
•few weeks afterwards, he suffered such severe pain in the upper part 
of the left arm as to indicate the probability of the bone being here 
diseased. The loss of the power of motion in his lower limbs became 
complete. His constitutional powers gradually failing, he sank about 
fourteen months from the commencement of the disease in the breast. 
The tumor occupying the situation of the mammary gland consisted 
throughout of a solid hard substance, which, in its composition, appear- 
ed to be identical with that of hard cancer in the female breast. The 
indurated axillary absorbent glands presented the same structure as 
the tumor of the mammary gland. In the left humerus, granules of 
carcinomatous substance, varying from the size of a pin's head to that 
of a pea, were scattered through the medullary tissue. About the 
centre of the bone, there was a large mass of carcinomatous substance, 
filling the medullary tube, and penetrating its walls. There also was 
carcinomatous substance deposited in the cancellous texture of the head 
and neck of the humerus ; and, in the latter situation, it extended 
completely through the walls, which had in consequence given way, in 
the manner of a spontaneous fracture. In the lower part of the right 
humerus, there was carcinomatous substance filling the medullary tube, 
and penetrating the walls of the bone. Within the sternum the can- 
cellous texture had wholly disappeared, and its place was occupied by 
carcinomatous substance extending through the bone. "Within the 
bodies of the five lower dorsal vertebrae, carcinomatous substance was 
deposited, and the entire body of one of these vertebrae had wholly 
disappeared, its place being occupied by the carcinomatous substance ; 
here, therefore, a vacancy existed in the front of the spine, communi- 
cating with the spinal canal. Opposite this vacancy, the spinal cord 
and its membranes were very vascular, but not otherwise unhealthy. 
Carcinomatous substance was deposited in the bronchial glands. Also, 
over the surface of each lung, immediataly beneath the pleura, there 
were numerous small carcinomatous deposits. The carcinomatous sub- 



208 HARD CARCINOMA, 

stance, found in the bones and in the internal organs, presented exact- 
ly the same character as that composing the tumor of the mammary 
gland*. 



CARCINOMA MELENODES (MULLER). 

Melanosis in soft structures consists in the deposition of fine molecules 
of a brown or black matter, either in the parenchyma of organs, or in 
the meshes of a fine fibrous or cellular tissue, in the form of a distinct 
tumor. The first is the almost invariable form of melanosis in bone, 
the brown or black matter being deposited in the tissue of the bone, 
either in isolated patches, or diffusedly through it. There have, how- 
ever, been instances, although very rarely, of the growth of a melano- 
tic tumor from a bone. One such case is related by Midler, in which 
v. Graefe removed a large lobulated melanotic tumor from the lower 
jaw, with the portion of the bone in which it originated! . 

Melanosis in bone has very rarely occurred as a primary disease ; its 
general, and perhaps invariable, character has been that of a seconda- 
ry disease, manifesting itself in instances where there had been mela- 
notic deposits in some of the soft structures, but more especially in the 
eye, and in the skin. 

The bones in which melanotic matter has been most frequently de- 
posited are, the cranium, ribs, vertebrae, and sternum ; and it has been 
found in several bones of the same individual. 

The deposit of melanotic matter in bone simply stains it, and produ- 
ces upon it no other effect ; no inflammatory action is, in consequence, 
set up in the bone, and none of the organic changes in it ensue, which 
are consequent on other morbid deposits in the osseous tissue. 

The following are examples of the melanotic deposit in bone. 

A case is related by J. F. Lobstein, in which the cancellous texture 
through the lower third of the femur was infiltrated with melanotic 
matter ; other deposits of the same character were found upon the pe- 
riosteum, and between the periosteum and the bonef . 

Two cases are related by Sir A. Halliday, in which melanotic mat- 
ter was deposited in various soft organs, and in several of tha bones : 

* These several specimens of carcinoma in bone are preserved in the museum of St. 
Bartholomew's Hospital. One of them is represented, Plate 17, fig. 4. 
f Essay on the Nature of Cancer. 
J Traite d'Anatomie pathologique, t. i. p. 460. 



AND MELANOSIS IN BONE. 209 

in one case, -the cancellous texture of the sternum, ribs, and cranial 
bones was blackened by it ; and in the other, the cranial bones alone*. 
In the museum of St. Bartholomew's Hospital, there are specimens 
of melanosis in the vertebrae, rib, and cranial bones, from the case of a 
young female, in whom melanosis formed in the skin of the back, and 
afterwards in nearly every organ of the bodyf. 

* London Medical Repository, June — September, 1823. 
t First series, Nos. 190, 191, 192. Thirty-fifth series, No. 23. 



18' 



PART IV. 



CHAPTER I 



MORBID GROWTHS FROM THE JAWS. 

There are diseases having their origin in the gum, or in the mucous 
membrane adjacent to it, which, in their progress, exhibit, in som3 re- 
spects, the features of morbid growths from the bone of the upper, or 
lower jaw. One of these dissases originating in the gum, is called 
Epulis, another form of disease, originating, either in the gum, or in 
the adjacent mucous membrane, exhibits the same characters as the 
disease originating in mucous membrane elsewhere, and designated 
Epithelial Cancer. 

DISEASE OF THE GUM DESIGNATED EPULIS. 

This disease appears either as a simple enlargement or hypertrophy 
of the gum, or as a circumscribed tumor growing from the gum, and 
occasionally attached to it by a narrow pedicle. It occurs in children, 
as well as in adults ; and it is usually of slow progress. It constitutes 
a hard, painless swelling, projecting from the alveolar border of the 
jaw. The surface of the swelling is at first smooth, but, in increasing, 
it becomes tuberculated, softened, and ulcerated, from the pressure of 
the teeth against it, and there is often profuse bleeding from it. As 
the swelling increases, it extends around the teeth and encloses them, 
and then it often appears to have originated in their sockets. 



212 MORBID GROWTHS 

In some instances, this disease is found to consist of nothing more, 
than enlarged and indurated gum ; but, in others, it consists of a 
dense fibrous tissue and irregularly scattered particles of bone. I re- 
moved one of these tumors from the outer plate of the alveolar pro- 
cess of the upper jaw, which was composed of a dense fibrous tissue, 
■with a nucleus of true bone. 

This disease presents no other feature of malignancy than its strong 
tendency to reproduction, if every particle of the morbid substance, 
with, besides, the surface, whether it be of a soft tissue, or bone, to 
^which it was attached, has not been completely removed. The pro- 
duction of this disease cannot be ascribed solely to irritation from de- 
cayed teeth, since it occasionally appears where the teeth are sound. 

There have been instances of this disease spreading from the gum 
into the mucous membrane of the palate, producing the enlargement 
and induration of it; and, in one case, which I saw, the morbid sub- 
stance had penetrated the socket of a molar tooth into the cavity of the 
antrum. 

In some instances of this disease, I have found the adjacent bone 
hardened by inflammation ; and in others, I have found the surface of 
the bone, which had been overlapped by the morbid structure, ulce- 
rated. 



DISEASE ORIGINATING IN THE GUM, OR IN THE ADJACENT MUCOUS 



This disease occurs in adults, and, in most instances, before the age 
of fifty. It commences in swelling and induration of the gum, or of 
the mucous membrane adjacent to it, and the diseased surface becomes 
wart-like and ulcerated. The disease spreads slowly, but widely upon 
the gum into the mucous membrane of the cheek and palate, or into 
the floor of the mouth. Deeply ulcerated clefts form in the diseased 
•mucous membrane, with the growth of soft fungous excrescences 
: around them. The morbid structure is very vascular; if cut into, or 
otherwise injured, it bleeds profusely. But little pain accompanies the 
disease ; and it does not affect the general health. I saw a case where 
it had been seven years in progress, yet the general health was unim- 
paired ; and in several other cases, the absence of pain in the diseased 
structures, and the good health of the patients, were especially ob- 
served. 



FROM THE JAWS. 213 

It is well to remark, that the development of this disease has ensued 
from the irritation excited in a simply enlarged and indurated gum. 
In one such case, which I saw, enlargement of the gum had existed for 
several months, when incisions were made into it, and these were filled 
with lint and powdered alum. The wounds degenerated into a foul 
ulcer with raised and everted edges, which- showed no disposition to 
heal. Caustics, and other irritants, were applied to the ulcer, but it 
spread widely upon the inside of the jaw and cheek, and through the 
gum and periosteum to the bone, and, at the same time, the absorbent 
glands under the jaw became enlarged and indurated. But with all 
this disease, the patient suffered no pain, and his health remained 
good until, from the extent of the disease, he was prevented taking 
sufficient food for his sustenance. Here, it appearecUbut little doubt- 
ful that a simple epulis, by the irritating treatment it had received, 
was converted into an epithelial cancer. At all events, the case in- 
structs us not to treat an epulis otherwise than by the removal of the 
morbid structure. 

Notwithstanding the slow progress of this disease, it presents ma- 
lignant features, in its tendency to invade the adjacent soft tissues, 
and in its contamination of the adjacent absorbent glands. As the 
disease spreads upon the upper or lower jaw, the morbid substance 
adheres to the bone, and dips into the sockets of the teeth, out of 
which, in consequence, it ■ray be supposed to have grown. 

Examination of the structure of epithelial cancer shows it to consist 
chiefly of a yellowish- white, soft substance, resembling the scrapings 
of macerated epidermis, and, under the microscope, exhibiting well- 
marked epithelial cancer-cells. In an instance of this disease originat- 
ing in the gum of the lower jaw, where I removed an absorbent gland 
enlarged to the size of a filbert, which lay upon the sub-maxillary 
gland, there was within the capsule of this absorbent gland a mass of 
soft, white substance, presenting the same resemblance to the scrap- 
ings of macerated epidermis, and the same cancer-cells as were ob- 
served in the growth detached from the alveolar border of the jaw. 
The bone adjacent to this disease has been found hardened in some 
cases, and ulcerated in others. 

TREATMENT OF EPULIS, AND OF EPITHELIAL CANCER OF THE GUM, &C. 

I include the treatment of these diseases under one head, as there 
is but one consideration involved in it — the necessity of thoroughly 



214 MORBID GROWTHS 

removing the diseased parts with the tissues to which they have ac- 
quired attachment. And, of course, this can be done far more satis- 
factorily when the disease, of small extent, is limited to its original seat. 
Therefore, it is important that the disease should be recognized before 
it has crept, as it is apt to do, irregularly and indefinitely into the sur- 
rounding structures. 

It is essential that the surface of bone, whatever may be its extent 
or situation, to which the morbid substance has acquired attachment, 
should be removed, for unless this be done, reproduction of the disease 
is almost sure to ensue. And when the disease has penetrated the 
alveoli, these must be freely removed to their extremities ; and, in the 
lower jaw, it wil^be expedient to remove with the alveoli, the canal in 
the bone, lodging the dental nerve and vessels ; for, in a case where I 
had taken away a large piece of the jaw through its entire depth, the 
dental canal was found filled with morbid substance, of exactly the 
same character as that which, originating in the gum, was attached to 
the alveolar border of the jaw. 

On the question of removing these diseases by the knife or caustic, 
my preference is decidedly for the former. Caustic, in any form, 
cannot fulfil with certainty and precision the essential condition of the 
operation, which is to remove the diseased structures with the healthy 
tissues to which they have acquired attachment. I have known some 
instances of these diseases, when of limited extent, successfully treated 
with caustic ; but I have known instances of its failure, even in expe- 
rienced hands, and under circumstances in which, I believe, the free 
excision of the diseased parts would have been the means of a perma- 
nent cure. 

The operative proceedings required in these cases, when, with the 
diseased soft parts, it is necessary to remove a considerable portion of 
the upper, or lower jaw, are the same as in the cases of morbid 
growths from the jaws presently to be considered. Here, however, it 
may be well to observe, that in the instance of an epulis, or epithelial 
cancer, spreading upon the lower jaw, it will be desirable to remove 
the portion of the bone to which the diseased structure has attachment, 
without extending the incision of the jaw through its entire depth. 
To preserve even a narrow portion of the base of the jaw is of conse- 
quence, as the outline of the face will not then be interfered with, nor 
will the powers of mastication be impaired, by the falling inwards of 



FROM THE JAWS. 215 

the portions of the bone which are left, as is likely to happen after the 
removal of the entire front of the jaw. 

The following case is a good illustration of the progress of an epulis, 
originating in the gum of the upper jaw, and of the operative proceed- 
ings required for its removal. 

Epulis on the Upper Jaw. A young female consulted Mr. Aber- 
nethy on account of an enlargement of the gum. He stated it to be 
a growth of cartilaginous substance from the gum, and advised its , 
removal, to which the patient would not consent. The enlargement 
very gradually increased, so that at the end of eight years from its. 
commencement, it formed a tumor, projecting into the mouth, the size 
of a walnut ; but it had been wholly free from pain. The chief di- 
rection of the increase of the tumor was from the gum upon the palate.. 
I was now desired to undertake its removal. To obtain a full view of 
its extent, I found it necessary to divide the cheek from the angle of* 
the mouth to the prominence of the os inalae. I then separated the^ 
tumor from the palate and alveolar process, denuding the bone of its 
periosteum ; and, in doing this, I found that part of the alveolar pro- 
cess had been absorbed, but the exposed surface of bone appeared to 
be so perfectly healthy in texture that the removal of it was not con- 
sidered necessary. About three hours after the operation, the patient 
ejected a pint of blood from her stomach ; this appeared to be the ac- 
cumulation of the blood, flowing from many small divided vessels, 
which had passed into the pharynx. 

The exposed surface of bone became speedily covered with healthy 
granulations, which soon acquired the smoothness and softness of the 
free surface of mucous membrane. There was no reproduction of the 
disease. The tumor was composed of granules of a firm unctuous sub- 
stance, contained in cells, divided by fibrous septa. 

This case presents an exception to the rule of removing the surface 
of bone from which an epulis grows ; still, however, the rule must re- 
main as the general result of experience. 

To the question, whether an epithelial cancer of the mouth is a fit 
case for the operation, when it co-exists with enlargement of the ab- 
sorbent glands under the jaw, I am disposed to reply, that its removal 
may with propriety be undertaken, when only one or two absorbent 
glands are enlarged, and when these are so moveable and superficially 
situated, as to admit of being easily taken away. This statement is 
founded on the present condition of our knowledge respecting the dis- 
ease here distinguished by the term Epithelial Cancer, which is to the 



216 MORBID GROWTHS 

effect of its possessing so much of the character of a local disease that, 
if the whole of the contaminated parts are taken away, the patient will 
have a good prospect of remaining well. Acting on this view of the 
subject, I have removed, with a satisfactory result, the whole chain of 
enlarged superficial absorbent glands from both sides of the groin in a 
case of epithelial cancer affecting the external genital parts in the fe- 
male. And in a case of the chimney-sweepers' disease of the scrotum, 
which is also an example of the epithelial cancer, with the removal of 
the entire integuments of the penis and scrotum, I have, at the same 
time, taken away the indurated absorbent glands from both groins ; the 
parts healed soundly, and so long as the patient remained under my 
observation, there was no return of the disease. 

MORBID GROWTHS FROM THE LOWER JAW. 

Most of these growths originate in the cancellous texture between 
the two plates of the jaw. Indeed, it is doubtful whether all the mor- 
bid growths stated to arise from the outer surface of the jaw, have not 
been instances of epulis, or epithelial cancer, originating in the gum, 
or mucous membrane adjacent to it, and, in their progress, acquiring 
attachment to the bone. 

The following are the varieties of morbid growth from the lower jaw 
which I have seen : there may be others, of rare occurrence, which I 
have not happened to meet with. 

1. A white, compact, opaque substance, through which particles of 

bone are scattered, originating in the interior of the jaw. 
This substance has not the same degree of firmness, or the 
semi-transparency and elasticity, or the noduled form of enchon- 
droma. It is not manifestly fibrous, yet it would probably be 
considered to belong to that class of morbid growths. 

2. A grey, dense, manifestly fibrous tissue ; in some instances origi- 

nating apparently in the interior of the jaw, and, in others, 
from its alveolar border and outer surface. It is probable, that 
in the latter case this was an epulis, commencing in the gum. 

3. Soft, encephaloid substance, originating in the interior of the 

jaw. 

4. Fatty substance, in granules, intermixed with cells containing a 

glairy fluid, originating in the interior of the jaw. 

5. A soft, very vascular substance, of the character of erectile tis- 

sue, originating in the interior of the jaw. 



FROM THE JAWS. 217 

6. Cartilaginous substance, with osseous particles scattered through 

it. In the museum of the College of Surgeons, there is an in- 
stance of this growth of great magnitude, from the jaw of an 
adult female. 

7. Membranous cysts, containing a glairy fluid, originating within 

the jaw. These cysts, in enlarging, usually cause expansion of 
the walls of the jaw, and they are found to possess more or less 
complete osseous parietes, apparently formed by hypertrophy 
of the cancellous texture of the jaw. Occasionally, the mem- 
branous cysts, instead of expanding the walls of the jaw, cause 
the absorption of its outer wall, so that the tumor they form, 
nrojects on the outside of the jaw. This disease is usually of 
slow growth ; and there have been instances in which the tu- 
mor of the jaw, formed by it, has acquired a large size. 

8. Osseous growths from the jaw ; exostoses. Some of these are so* 

hard as to be ivory-like ; others not so hard, being composed of f 
cancellous texture. There are, also, growths from the jaw,, 
consisting in part of soft fibrous tissue, and in part of osseous; 
substance. In such tumors, the osseous substance usually con- 
stitutes their base, and it is disposed, either in a solid mass, or 
in laminae and fibres, hence the appellation which has been be- 
stowed upon this disease, " the foliated, or needle-shaped exos- 
tosis. " 

In the instances of the simple, hard, osseous exostosis, it may be ex- 
pected, that the part of the jaw from which it grows will be healthy ; 
but not so with respect to the other growths from the jaw. Most of 
these originate in disease of the bone. 

The cartilaginous tumor of the lower jaw is that which grows to the 
largest size. An ulcerative, or sloughing, process has, in some instan- 
ces, ensued in the centre of this tumor, analogous to the softening and 
breaking up of cartilaginous tumors growing from other bones. 

Morbid growths, originating within the lower jaw, are usually, in 
part, surrounded by a thin osseous shell, and intersected by thin osse- 
ous plates, apparently some remains of the original walls and cancel- 
lous texture of the bone. The thin osseous shell of the tumor is dis- 
covered by its yielding to pressure, with a sense of crepitation, and by 
its recoil, when the pressure is remitted. This character belongs more 
particularly to the tumor of the jaw caused by the formation of mem- 
branous cysts within it; for in this disease, more than in any other to 
19 



218 MORBID GROWTHS 

which the jaw is liable, the walls of the bone are likely to become ex- 
panded into a thin crepitating shell, and hence the recognition of it has 
been set down as a diagnostic sign, distinguishing this from other dis- 
eases of the jaw. 

A morbid growth, originating within the lower jaw, usually projects 
from its alveolar border into the mouth, before it causes any expansion 
of the walls of the bone, and thus the disease first appears around the 
necks of the teeth, or protrudes from the socket of a recently extract- 
ed tooth. When the disease is confined to the inner or outer side of 
the jaw, it may be suspected to have originated in the surface of the 
bone ; or, more probably, that it was an epulis, or epithelial cancer, 
originating in the gum. In some rare instan ces, the tumor of the jaw 
in enlarging, instead of projecting into the mouth, has extended down- 
wards into the neck. 

Morbid growths from the lower jaw occur most frequently in the ear- 
ly and middle periods of fife, rarely in old age. 

An osseous cyst, originating in the outside of the lower jaw, has so 
closely resembled the tumor of the jaw resulting from the expansion of 
its walls, as to render the diagnosis somewhat difficult. In illustration 
of this point, I relate the following case, which occurred in St. Bartho- 
lomew's Hospital, under the care of Mr. Earle. A man, aged twenty- 
three, was admitted, with a tumor projecting from the outside of the 
jaw, midway between its symphysis and angle. It was of the size of a 
walnut, smooth and round, its base was firm, but its central and most 
prominent part yielded to pressure, with a crackling sensation. It was 
stated, that the tumor had commenced three years previously, and that 
it had increased very slowly, and without pain. Doubt arising with 
respect to the sort of connexion which the tumor had with the jaw, 
part of it was separated from the bone, which exposed a large cavity 
filled with a glairy fluid. Further exposure of this cavity showed the 
tumor to consist of an osseous cyst, attached to the outside of the jaw. 
A thick, very vascular, membrane lined the cyst, and within it, the ca- 
nine tooth of the second set was seen projecting, with its fang attached 
to the membrane fining the cyst. About two-thirds of the cyst were 
taken away, and the rest of it was left attached to the jaw, but it did 
not interfere with the healing of the wound and the complete cure of 
the disease*. 



* Portion of the cyst which was removed. Museum of St. Bartholomew's Hospital, 
First series, No. 119, Plate 18, fig. 2. 



FROM THE JAWS. 219 

Morbid growths from the lower jaw, even when of large size, are 
usually more favourable for removal than those originating in the upper 
jaw, their outline and connexions being, in general, better denned : 
they do not extend indefinitely into the surrounding osseous and soft 
structures, as the tumors of the upper jaw are apt to do. According- 
ly, provided that the tumor of the lower jaw does not present features 
of malignancy, although it may be of great size, and implicate a large 
portion of the jaw, the removal of the tumor, and of the portion of 
the bone from which it has arisen, can be effected with certainty, and 
with the prospect of a satisfactory result. For it is true, that opera- 
tions upon the lower jaw are, in general, followed by a less amount of 
constitutional disturbance, than ordinarily ensues from operations of the 
same magnitude in other situations. The results of these operations 
which have been performed at St. Bartholomew's Hospital fully agree 
with this statement : and, in seven cases which have been recorded by 
Mr. Cusack, the patients, with one exception, had in a few weeks com- 
pletely recovered from the operation. In the unfavourable case, ery- 
sipelas ensued, terminating in sero-purulent effusion into the cellular 
tissue around the larynx and within the glottis*. It is recorded, that 
Dupuytren removed portions of the lower jaw in eighteen or twenty 
cases ; that in one of these, the result was fatal, from inflammation ex- 
tending to the larynx, and that in two others, the disease, which was 
stated to be cancer, recurred at distant periods ; but that, with these 
exceptions, the operations were successfulf . In one of the cases, 
where I removed the portion of the jaw between its symphysis and ra- 
mus, no constitutional disturbance ensued ; the whole tract of the wound 
united by adhesion ; and on the eighth day the patient left her bed 
and moved about in good health. 

A large proportion of the tumors of the lower jaw are local diseases 
of an innocent character ; but it is to be remembered, that there are 
morbid growths originating in the lower jaw, which contaminate the 
absorbent glands and other parts in their neighbourhood. Here, as 
elsewhere, it is difficult to distinguish, by their external characters, the 
tumors which are malignant from those which are not so ; and, like the 
morbid growths from other parts, it has happened that a tumor of the 
lower jaw, which presentid no malignant feature in its early stage, has 
suddenly, perhaps after the lapse of years, assumed wholly new charac- 

* Dublin Hospital Reports, Vol. iv. 
t Lecons Orales, t. iv. p. 65. 



220 MORBID GROWTHS 

ters, then rapidly increasing, becoming painful, and undergoing the 
changes of malignant disease. 

OPERATIONS UPON THE LOWER JAW. 

When considering the operations upon the upper jaw, an objection 
will be urged against the use of chloroform, or aether in these opera- 
tions, on the ground, that the glottis, deprived of its irritability, may 
permit the passage of blood into the trachea. This objection does not 
apply so forcibly to operations upon the lower jaw ; the parts implicat- 
ed in them not being so deeply situated, the blood will more readily es- 
cape through the external wound. But to guard against the possibili- 
ty of its descending towards the larynx, the patient, during the opera- 
tion, should sit upright, without reclining in the least. 

In the removal of morbid growths from the lower jaw, the incisions 
require, of course, to be varied according to the situation and extent 
of the disease, which is not always possible beforehand to ascertain. 
Thus disease originating within the jaw, is occasionally found to extend 
through its cancellous texture much beyond the limits indicated by the 
enlargement, or other alteration, of the bone. 

In instances where a morbid growth of small extent implicates only 
a portion of the front of the lower jaw, its removal may be effected by 
an incision wholly within the mouth, and, accordingly, without any ex- 
ternal wound. If, in such a ca,se, it is deemed necessary to divide the 
skin, an incision should be made along the lower edge of the jaw, of 
sufficient extent to allow a flap of integuments to be turned upwards. 

For the removal of a tumor occupying one lateral half of the body 
of the jaw, from the angle to the symphysis, a single incision will be 
sufficient, commencing a little above the angle, and continued in a curv- 
ed line downwards and forwards, along the base of the jaw, and then 
a little upwards upon the chin. If the tumor is large, or implicates 
the ramus of the jaw, it may be necessary to continue the incision 
from the chin upwards, through the middle of the lip, in order that a 
flap of skin, comprising the entire cheek, may be reflected upwards, 
for the object of bringing the whole extent of the disease into view. 
Or, such may be the form and situation of the tumor, that it will be 
expedient to extend the incision from the ear, straight downwards to 
the angle of the jaw ; next, along its lower edge to the chin, and then 



FROM THE JAWS. 221 

upwards, through the middle of the lip. Thus a large flap of skin will 
be formed, comprising the entire cheek and half of the lower lip. It 
is desirable so to direct these incisions, that the cicatrix they will leave 
may be away from the front of the face ; also, that the parotid duct 
and the principal branches of the portio dura may not be interfered 
with. 

The several steps of the operation of removing a portion of the low- 
er jaw, are to be executed in the following order : first, the removal of 
any teeth that may be in the way of the division of the jaw ; second- 
ly, the incision of the skin, and its separation, with the subjacent mus- 
cles, from the outside of the jaw ; thirdly, the division of the bone ; 
and, fourthly, the detachment of the soft parts from the inside of the 
jaw. Thus will be left, to the last stage of the operation, the only 
proceeding with which danger is connected, namely, the detachment of 
the genioglossi muscles from the jaw, which might be followed by re- 
traction of the tongue. Whilst the saw is in action, a narrow spatula, 
pushed upwards on the inside of the jaw, will protect the soft parts 
from injury. 

It may be necessary, before completing the incisions, to tie the di- 
vided ends of the facial artery, and any bleeding vessels there may be 
in the deeper part of the wound should be secured, that there may be 
no risk of secondary haemorrhage. In some of the operations which 
have been performed upon the lower jaw, a ligature was placed, in 
some cases, upon the common carotid, in others, upon the external ca- 
rotid, as a security against haemorrhage ; but the divided vessels bled 
as freely as if this had not been done. A large portion of the lower 
jaw may be removed without dividing any other artery, of consequence, 
than the facial. Deep-seated arteries of magnitude are to be avoided, 
by making the incisions close to the bone, or to the tumor occupying 
its place. Further, it is to be observed, that whilst the disease is in 
progress, the adjacent arteries, even when of large size, often become 
obliterated, so that when divided, no bleeding ensues. 

Every care is to be taken, in dressing the wound, to secure the union 
of the divided integuments by adhesion. The use of many fine sut- 
ures, with thin pins and strips of isinglass plaster placed over them, 
are the best means of obtaining this desirable result. 

When the disease is confined to the alveolar border of the jaw, the 
removal of it may be effected without extending the division of the bone 
to its base. Sir P. Crampton, in such a case, removed a triangular 

19* 



222 MORBID GROWTHS. 

piece of the jaw, including the sockets of the two small molar teeth, by 
means of a fine watch-spring saw, and there was no reproduction of the 
disease*. It is certainly most desirable, whenever practicable, to leave 
the base of the jaw entire ; for, however narrow the portion of bone 
may be that is left, it will preserve the natural outline of the face, and 
prevent any material interference with the powers of mastication. 

After the removal of a large portion of the front of the jaw, includ- 
ing its base, the lateral portions of the bone are very apt to fall in- 
wards, whereby the molar teeth cannot be applied to those of the upper 
jaw, and thus the power of mastication will be wholly lost. In such 
instances, the two portions of the jaw do not fall inwards simply from 
the want of support, but they are drawn forcibly inwards by muscular 
action, probably by the mylohyo'idei muscles. In a youth, from whom I 
removed a large portion of the front of the jaw, the lateral portions of 
the bone became drawn so considerably inwards that he wholly lost the 
power of mastication. I interposed wedges of cork between the two 
portions of the jaw, and tried various other contrivances, but ineffectu- 
ally ; the molar teeth could not be brought opposite to those of the up- 
per jaw. Subsequently, however, this patient derived much advantage 
from the adaptation of a row of false teeth to the two portions of the 
jaw. It improved the appearance of the mouth, supported the lower 
lip, and prevented the constant flow of the saliva over it ; and it ap- 
peared probable, that, by means of the false teeth, he would, in some 
degree, regain the power of mastication. 

In order to guard against the ill consequences just described, after 
taking away the front of the lower jaw, it is desirable that, from the 
time of the operation, the two lateral portions of the bone should be 
kept in their places by inserting between them an arch of ivory, hav- 
ing its extremities fixed to the molar teeth by metallic caps, or rings, 
enveloping them ; or, for the same object, it has been recommended 
that a silver plate, hollowed on its upper and lower surfaces, for the re- 
ception of the molar teeth, should be constantly worn in the mouth ; 
and to obtain the full advantage of this proceeding, it will be necessary 
to have the silver plate fitted to the crowns of the molar teeth some 
days previous to the operation. 

When it is intended to remove the entire ramus, it may be conveni- 
ent to divide the jaw a little below its neck ; and then, after removing 
the tumor and the portion of the jaw connected with it, to disarticulate 

* Dublin Hospital Reports, Vol. it. 



FROM THE JAWS. 223 

the condyle. The joint of the jaw should be opened on its front part ; 
if this be done from behind, there will be danger of wounding the 
internal maxillary artery, from its proximity to the incisions. 

In an instance of disease confined wholly to the ramus of the jaw, 
its removal, with the disarticulation of the condyle, can be effected by 
an incision directly over the ramus, and continued around it, but not 
extending into the cavity of the mouth. Mr. Syme has recorded a 
case showing the successful result of this proceeding*. 

The division of the jaw will be conveniently effected, either by the 
saw alone, or by first making a deep groove in the bone with the saw, 
and completing its division with the cutting forceps. 

When removing the front of the jaw, on separating the genioglossi 
muscles from the bone, the tongue has been retracted into the mouth 
so deeply as to cover the glottis, and thus to cause suffocation. Dr. 
Warren states that, in removing an extosis of the lower jaw, " when 
about to sever the lowest remaining muscles, he perceived the tongue 
drawn back into the pharynx, and the patient in a state of suffocation." 
He adds : " Immediately seizing the tongue with the left hand, I drew 
it out of the pharynx, and, confiding it to a friend, completed the sec- 
tion, and prepared a large needle and ligature to transfix it. ^This hap- 
pily was not necessary. After waiting five minutes, the spasmodic ac- 
tion ceased, and did not returnf ." Dupuytren refers to a case, in 
which, to prevent suffocation, tracheotomy was at the instant perform- 
ed ; and he states, that in his own operations, he had prevented retrac- 
tion of the tongue by grasping its point firmly, with the aid of a piece 
of dry linen, at the instant of dividing its attachments to the jaw$. 
Other instances of retraction of the tongue, in operations upon the jaw, 
have been recorded by Lisfranc, and by Velpeau§. 

It is probably by the action of the styloglossi muscles, that the 
tongue is drawn backwards into the pharynx, when the antagonizing 
power of the genioglossi muscles is lost. Retraction of the tongue did 
not occur in any of the operations upon the lower jaw which I have 
witnessed. At the instant of its occurrence, the operator should be 
prepared to seize the apex of the tongue, and draw it forwards with 
the help of a piece of dry linen. Security against its retraction may 
be obtained, by passing through its apex, a strong thread, by means of 

* Contributions to Pathology and Surgery, 8vo. 

t Surgical Observations on Tumors, p. 115. 

X Lecons Orales, t. iv. 

§ Lancette Franchise, Aout, 1836. Elements de Medicine Operatoire, t. i. p. 546. 



224 MORBID GROWTHS. 

which it can.be kept forwards during, and for sometime after, the 
separation of the attachments of the genioglossi muscles from the jaw. 

The utmost extent of the reproductive power, ensuing after the re- 
moval of a portion of the lower jaw, consists in the formation of a 
dense fibro-cellular tissue between the ends of the bone, connecting 
them so firmly that the two portions will move accurately together, and 
with sufficient force for mastication. 

A case has been recorded, in which both lateral portions of the 
lower jaw, leaving only a small portion of it at the symphysis, were 
removed at two operations, with an interval of six years between them. 
A tumor arose from one side of the jaw, and afterwards a similar tu- 
mor arose from its other side. On the right side, the sections of the 
jaw were made a little above the angle, and a little anterior to the 
mental hole. On the left side, the condyle was disarticulated, and the 
anterior section was made immediately in front of the canine tooth. 
The advantages derived from leaving the symphysis were, that the 
attachments of the genioglossi muscles being preserved, the retrac- 
tion of the tongue was prevented, also that the support of the lower 
lip being preserved, the constant flow of the saliva from the mouth was 
prevented ; it was, besides, considered, that if the attachments of the 
genioglossi muscles were preserved, the patient would be better able to 
speak and to swallow. The result of this case was most favourable*. 

The operation of removing portions of the lower jaw, constitutes one 
of the most remarkable of the achievements of modern surgery. It 
appears, that the first of these operations was performed by Mr. White, 
at the Westminster Hospital, in the year 1804. But it does not ap- 
pear that the operation was repeated until the year 1821, when it was 
performed by Dr. Valentine Mott, of New Yorkf. 

MORBID GROWTHS FROM THE UPPER JAW. 

Morbid growths from the upper jaw, in a large proportion of cases, 
originate within the antrum. Hence, with reference to the operations 
required for their removal, an exact knowledge of the relations of the 

* Case by Mr. Spence. Edinburgh Medical and Surgical Journal, April, 1843. 
t Medical Gazette, March, 1846. 



FROM THE JAWS. 225 

walls of the antrum to the adjacent bones is of so much importance, 
that I shall here introduce the following particulars in the anatomy of 
this part of the superior maxillary bone. 

The upper wall of the antrum is the floor of the orbit; its posterior 
wall is the boundary of the zygomatic fossa ; its lower wall comprises 
the sockets of the bicuspid and molar teeth ; its inner wall is the boun- 
dary of the nose ; and its front wall is the boundary of the cheek. 
The several walls of the antrum are thicker in the child than in the 
middle period of life. The upper wall is the thinnest. 

The cavity of the antrum has, in most instances, the form of a tri- 
angular pyramid, with its apex towards the os malse, and base towards 
the nose. Thin plates of bone are often found extending across the 
cavity. The dimensions of the central part, or body, of the superior 
maxillary bone, indicate the extent of the antrum. A good practical 
view of the extent of its cavity is furnished in the following history : — ■ 
" A lady suffering tooth-ache, submitted to the extraction of the canine 
tooth of the upper jaw, with which a portion of the alveolar process 
was removed, making an aperture in the antrum, from which a watery 
fluid constantly issued. The patient, desirous of ascertaining the source 
of the discharge, took a pen, and having stripped off the barbs from 
the feathered part, she found that the whole of it, full six inches long, 
could be introduced into the cavity. At this she was greatly terrified, 
believing it must have gone into the brain. She consulted Highmore, 
who explained to her that the pen had turned spirally within the sinus, 
and he, besides, counselled her to submit with patience to the inconve- 
nience of the discharge from the cavity*. " 

In the inner wall of the antrum, is the aperture of communication 
with the nose. In the separate bone, this is, in some instances, single, 
and so large as to allow the passage of the little finger through it ; 
in other instances, there are two small apertures, separated by a thin 
plate of bone. In the entire and recent head, the aperture is so 
much narrowed by the ethmoid bone, by the vertical plate of the pal- 
ate bone, and by the inferior spongy bone, as well as by the pituitary 
membrane passing through it, that it will but just admit the passage of 
a probe. This aperture is usually situated at some distance from the 
lower wall of the cavity ; consequently, in the erect posture, fluid will 
not escape from the antrum until a certain quantity has accumulated 

* Drake's System of Anatomy. Two vols. 8vo. 1707. 



226 MORBID GROWTHS 

within it. Only in the horizontal posture, and with the opposite cheek 
downwards, will the aperture in the antrum be favourably situated for 
the passage of fluid into the nose. In some instances, from the dis- 
position of the pituitary membrane, the aperture is very oblique. 
There may be one or more small apertures in the lower wall of the 
.antrum, communicating with the sockets of the molar teeth. 

The membrane lining the antrum is thin, loosely adherent to the 
bone, but little vascular, and smooth on its free surface ; its characters 
more resemble those of serous than those of mucous membrane. 

Although, in the operation of taking away the superior maxillary 
bone, the proceedings are necessarily varied according to the extent of 
the disease, it may be well to mark the lines of connexion of the supe" 
rior maxillary with the adjacent bones. The posterior part of the 
superior maxillary bone is simply in contact with the front surface of 
the pterygoid process of the sphenoid bone. The lines of firm osseous 
connexion of the superior maxillary with the adjacent bones are, infe- 
riorly and mesially, by its alveolar and palatine processes, with the 
opposite bone ; posteriorly, by its palatine process, with the palate 
bone ; superiorly and internally, by its nasal process, with the nasal, 
frontal, and lachrymal bones, also by its orbitar process, with the 
lachrymal and ethmoid bones ; superiorly and externally, by its orbitar 
and malar processes, with the malar bone. 

In explanation of the fact, that morbid growths arise in the an- 
trum more frequently than in any other nasal sinus, its direct connexion 
with the sockets of the molar teeth has been usually referred to. 
Certainly, in a large proportion of cases, disease in the antrum can be 
traced to the irritation from decayed teeth, or to the rude and unskilful 
efforts of dental surgery. In a case which occurred to Mr. Luke, at 
the London Hospital, a fibrous tumor, filling the antrum, originated in 
the alveolar process, and within the base of the tumor, a black carious 
tooth was imbedded* ; and, in other instances, the origin of the tumor 
in the antrum in some source of irritation connected with the teeth, 
was probable, from its being attached only to the lower and front wall 
of the antrum, where are the sockets of the molar and bicuspid teeth. 
Further, it is to be observed, that morbid growths mostly arise from 
either of the lateral parts, not from the front of the jaw ; a fact which 
might be explained by the consideration that irritation more frequently 

* Plate 16, fig. 8. 



FROM THE JAWS. 227 

originates in a molar than in an incisor tooth. A similar view of the 
origin of diseases in the antrum is set forth by M. Bordenave, in his 
Memoir on this subject*. Occasionally, however, these diseases do 
occur independently of sources of irritation connected with the teeth. 
In India, the natives are remarkable for the soundness of their teeth, 
yet they are subject to morbid growths from the jaws, of the same 
character with those which occur in this country f . 

Morbid growths in the antrum have, in some cases, commenced in 
early life ; in others, at an advanced age. In one case which I saw, 
the disease commenced at the age of four years. In a case recorded 
by M. Gensoul, a morbid growth commenced in the antrum of a woman 
in her fifty-ninth year$ ; and I have seen a case wherein a morbid 
growth, filling the antrum, and causing the expansion of its walls, 
commenced in a female seventy-six years of age. 

Morbid growths from the superior maxillary bone, are of a fibrous, 
cartilaginous, encephaloid, fatty§, erectile, or osseous nature. 

The osseous growths from the superior maxillary bone are, in some 
instances, combined with hypertrophy of the surrounding bones, pro- 
ducing a general enlargement of them. The cartilaginous tumors are 
the most favourable for removal ; not only because they present more 
of the characters of local affections, and do not contaminate the adja- 
cent absorbent glands, or deteriorate the general health ; but espe- 
cially, for the reason, tnat they are usually of a globular form, do not 
extend irregularly into the adjacent parts, and, in consequence, can be 
removed with the certainty of taking away the whole of the morbid 
structure. In the first case in which M. Gensoul removed the superior 
maxillary bone, a fibrocartilaginous tumor, of the size of the closed 
hand, originated in the antrum. It was globular, had an even surface, 
a well-defined outline, and loose cellular connexions with the adjacent 
parts || . The encephaloid, and fatty tumors, on the contrary, are 
much less favourable for operation, as the morbid deposit is apt to 

* " La carie des dents est la cause de presque toutes les maladies du sinus max- 
illaire et de celles qui affectent les parties circonvoisines." Precis d'observations sur 
les maladies du sinus maxillaire, par M. Bordenave, Mem. de l'Academie Koyale de 
Chirurgie, t. xii. 12mo. 

t On diseases of the Jaws, by Eichard O'Shaughnessy. Calcutta, 1844. 

t Lettre chirurgicale sur quelques maladies graves du sinus maxillaire, et de l'os 
maxillaire inferieure. Paris, 1833. 

§ Composed of granules of a greasy substance, of the character of stearine. || Loc. cit. 



228 MORBID GROWTHS 

extend indefinitely among the surrounding parts, so that it is difficult, 
often impossible, to effect its complete removal. Even an osseous ex- 
ostosis, growing from the walls of the antrum into its cavity, may not 
be a well-defined disease, as it may be combined with hypertrophy of 
the bones of the face and cranium. An erectile tumor growing from 
the antrum, is a rare form of disease ; it occurred to M. Gensoul in one 
of the cases wherein he successfully removed the superior maxillary 
bone. The tumor was soft and vascular, and quicksilver impelled into 
the morbid structure readily pervaded it throughout*. 

In completion of the view of the diseases which originate in the an- 
trum, it should be observed, that there is a class of cases, apparently 
commencing in collections of fluid within the antrum, but followed by 
malignant ulceration of its walls ; not, however, accompanied by any 
morbid deposit, and, therefore, not presenting, in any stage, the char- 
acters of a distinct tumor. 

Instances have occurred wherein the disease designated epulis, ori- 
ginating in the gum, thence extended through the socket of a molar 
tooth into the antrum, in which, consequently, the disease was suppos- 
ed to have originated. Such were the circumstances of the following 
case. In a man, thirty years of age, a tumor projected into the mouth 
from the back part of the alveolar border of the upper jaw ; it was 
firm and noduled on its surface. The painful state of the whole side 
of the face, combined with a projection of the front wall of the an- 
trum, were considered to indicate that the disease had originated with- 
in it. Two attempts w T ere made to scoop out the morbid structure 
through the alveolar border of the jaw, by breaking away the parti- 
tions between the sockets of the molar teeth ; but, after each opera- 
tion, the disease was rapidly reproduced. So much constitutional de- 
rangement followed these operations, that the man's health declined, 
and he sank. On examining the seat of the disease, it was found that 
the morbid structure originated in the gum ; and that, although it com- 
pletely filled the antrum, it had no connexion with its walls : the mem- 
brane lining the antrum was healthy. 

Much care is requisite in the diagnosis between enlargement of the 
antrum, by a morbid growth within it, and the expansion of its walls 

* Loc. cit. 



FROM THE JAWS. 229 

by fluid accumulated in its cavity. When the enlargement of the an- 
trum is accompanied by a thinning of its front wall, the swelling may 
yield to pressure, and communicate to the fingers a peculiar crepitating 
sensation. But the enlargement of the cavity of the antrum is, in 
some instances, accompanied by hypertrophy of its walls, giving to the 
tumor the characters of a solid mass of bone. The following case of 
this kind occurred in St. Bartholomew's Hospital, under the care of 
Mr. Lawrence. A woman, aged twenty-four, was admitted, with a 
large, hard, round swelling of the cheek, in the situation of the an- 
trum ; it was free from pain, and the soft parts covering it were heal- 
thy : such was the solidity, and the hardness of the swelling, that it 
was supposed it might be an osseous growth from the antrum ; and the 
history appeared to confirm this view of its nature, as the woman stat- 
ed, that, about five months previously, she received a blow on the 
cheek, and that soon afterwards, the swelling commenced, and had 
slowly increased to its present magnitude, which was about that of a 
middle-sized orange. A scalpel was thrust into the tumor, immediate- 
ly above the sockets of the molar teeth, and healthy pus flowed from 
the opening ; the discharge continued, in gradually decreasing quanti- 
ty, and the swelling subsided as the walls of the antrum receded to 
their natural limits. 

One such case as the foregoing indicates the propriety of not com- 
mencing the extirpation of a tumor of the antrum, without previously 
plunging an instrument into it, to be certain of its solidity. The fol- 
lowing case, recorded by M. Gensoul, affords a further illustration of 
this point. A child, thirteen years of age, had a large tumor in the 
cheek ; the arch of the palate was depressed, the nostril closed, and 
the nose pushed to the opposite side of the face. It was determined 
to remove the superior maxillary bone. Tbe incisions in the soft parts 
had been made, when it occurred # to M. Gensoul to pass an instrument 
into the tumor before dividing the bone. A yellow fluid escaped from 
the antrum, and, on freely opening its cavity, this was found greatly 
enlarged, and its lining membrane of a red colour, but not other wise 
altered. On passing a finger into the antrum, the canine tooth was 
found lying in the bottom of the cavity, and adhering to its walls. The 
operation was here concluded. M. Gensoul expresses his hope, that 
the candid avowal of his error in the diagnosis of this case, will have 
the effect of directing the attention of surgeons to the various sources 
of these swellings, and that, before deciding upon their removal, they 

20 



230 MORBID GROWTHS 

will carefully examine them, and particularly ascertain that the process 
of dentition has been completed*. 

A tumor gradually increasing within the antrum may occasion the 
yielding of^its walls, equally and in all directions. By the yielding of 
its front wall, a round prominence will gradually advance into the 
cheek ; by the yielding of its inner wall, and of the septum nasi, the 
nostril will become closed, and the nose pushed to the opposite side ; 
by the yielding of its upper wall, the tumor extending into the orbit 
will displace the eye forwards, and probably upwards and outwards ; 
and, lastly, by the yielding of the palate, the tumor will project into 
the mouth. But, in some cases, the disease extends chiefly in one di- 
rection; and, under such circumstances, the diagnosis of it will proba- 
bly be difficult. In a case which I saw, where a morbid growth origi- 
nating, within the antrum, had extended only in the direction of the 
nostril, portions of it had been extracted by the polypus-forceps, under 
the supposition that it grew from the pituitary membrane ; and there 
is a case recorded, wherein an operation having been commenced for 
the removal of an osseous tumor, which projected into the orbit, and 
was supposed to have originated in its walls, it was discovered that the 
tumor extended into the antrum, and, consequently, only the portion 
within the orbit was removedf. 

In investigating the connexions of a tumor originating in the antrum, 
a probe should be passed along the floor of the nostril, to learn the ex- 
tent of it in this direction, and the finger should be turned around the 
posterior border of the soft palate to its upper surface, to ascertain if 
any part of the tumor can be here recognized. But, even with the 
help of the most careful examination, whenever the disease fills the an- 
trum and the nostril, it will be uncertain whether or not it extends pos- 
teriorly beyond the front surface of the pterygoid process of the sphe- 
noid bone. If it does so, it will be # beyond the reach of any incisions 
that can safely be made for its removal, and, accordingly, in operations 
which I have witnessed, where the whole of the diseased structure was 
not removed, it had penetrated the pterygoid process, or had encroach- 
ed upon the lateral borders of this process, or it had extended upwards 
towards the basis of the skull. 

The question of an operation in these cases mainly rests on the state 
of the general health, on the extent and connexions of the disease, and 

* Loc. cit. 

1 Encyclographie des Sciences Medicales, Novembre, 1S34. 



FROM THE JAWS. 231 

on the condition of the parts around it. The circumstances of the case 
considered to be fit for operation, ought to be such as to afford the full- 
est ground for believing that the incisions can be made through healthy 
parts, beyond the limits of the disease. In no case can it be justifiable 
to return to the ancient methods of scooping out, or in other ways ex- 
tracting part of the morbid structure, and trusting to caustics for the 
destruction of the remainder. To M. Bordenave the merit is due of 
originally suggesting sound views of the nature and treatment of these 
diseases. He insisted on the propriety of not undertaking an opera- 
tion, when there was uncertainty respecting the possibility of taking 
away the whole of the disease ; and he has related several instances of 
permanent cure, after the extraction of tumors from the antrum*. 
But, to Mr. Lizars, of Edinburgh, the merit is due, of showing that 
the only satisfactory mode of treating these cases is by the removal of 
the entire superior maxillary bone, and of explaining the proceedings 
for its accomplishment! . Mr. Lizars is, therefore, to be regarded as 
the originator of this operation, the propriety of performing which, in 
certain cases, is abundantly proved by the experience of modern times. 
To Mr. Liston we are indebted for a discrimination of the cases in 
which the operation may with propriety be undertaken J. Further, in 
the memoir of M. Gensoul, there are valuable records of experience 
on this subject. 

OPERATIONS UPON THE SUPERIOR MAXILLARY BONE. 

One consideration, it has appeared to me, belongs to all operations 
performed for the removal of either a portion, or the whole of the su- 
perior maxillary bone ; namely, that they are cases in which a serious 
objection lies against the use of either chloroform or aether ; for, inas- 
much as by the influence of these agents in annihilating sensibility, the 
irritability of the glottis is weakened, if not wholly lost, so there must 
be danger of a trickling of blood from the mouth of the glottis, with- 
out the excitement of a cough to expel it from the windpipe. It is 
true, that the amount of this danger is but small ; but, in my mind, it 
is sufficient to know that the apprehended evil has once occurred : se- 
vere as the pain of these operations may be, it had better be endured 
than the risk of suffocation incurred, which must be regarded as a pos- 

* Loc. cit. 

t A system of Anatomical Plates, Part IX. Organs of Sense, 1826. 

| On Tumors of the Mouth and Jaws, Medico- Chirurgical Transactions, Vol. xx. 



232 MORBID GROWTHS 

sible occurrence, from the filling of the pulmonary air-tubes and cells 
with blood. 

OPENING THE ANTRUM FOR THE EXTRACTION OF A MORBID GROWTH 
FROM ITS CAVITY. 

For the extraction of a morbid growth from the cavity of the an- 
trum, a wide opening into it is requisite, and this can be obtained in no 
other way than by removing part of its front wall. Formerly, for this 
object, a trephine or perforator was applied to the alveolar border of 
the jaw ; but the opening into the antrum thus made will be insufficient 
for obtaining a full view of its cavity. Bordenave assigns the merit of 
first proposing the perforation of the front wall of the antrum to M. 
Lamorier, of Montpellier. His directions for the operation are such 
as surgeons at the present time adopt — to divide the gum and perioste- 
um, immediately above the socket of the first molar tooth, then, with a 
perforator, to penetrate the bone, and afterwards to enlarge the open- 
ing to the requisite extent. 

For the removal of the whole front wall of the antrum, it is necessa- 
ry to reflect from it, the integuments and muscles of the cheek. The 
incision of the integuments for this purpose should extend from the in- 
ner corner of the orbit vertically downwards, by the side of the nose 
and through the upper lip. Next, the mucous membrane is to be di- 
vided horizontally, in the line of its reflexion from the cheek to the 
gum, and then the flap, formed by the integuments and muscles of the 
cheek, is to be detached from the bone, and turned upwards to the 
margin of the orbit. It has been recommended, that the flap of integ- 
uments and muscles should be formed by an incision, extending from 
the prominence of the os malae, in a curved line with the convexity 
downwards to the angle of the mouth. But, to this line of incision, 
there is the objection, that it will include the principal branches of the 
portio dura. Attention is required to the point, of taking away any 
portion of the wall of the antrum that is unsound. As the morbid 
growth frequently originates in the lower and front part of the antrum, 
along the line of the alveolar process, it may be necessary to remove 
part of this process. Mr. O'Shaughnessy has related a case, in which 
he removed the anterior wall of the antrum, and, with it, a fibro-car- 
tilaginous tumor filling its cavity, and there was no recurrence of the 
disease*. 

* Loc. cit. 



FROM THE JAWS. 233 



REMOVAL OF THE SUPERIOR MAXILLARY BONE. 

The following considerations should be present in the mind of the 
surgeon, when deciding on the question of the removal of part, or 'the 
whole, of the superior maxillary bone. 

The yielding or enlargement of the bony wall of the antrum towards 
the cheek, orbit, or mouth, is the evidence of its cavity being filled by a 
solid or fluid morbid product. If its wall has yielded only towards the 
cheek, its cavity may be filled only by fluid ; or if it be filled by a solid 
substance, this may have arisen in the gum, and extended through the 
alveolus of a tooth into the antrum ; or it may have grown from a 
small portion of the wall of the antrum, and this will most probably be 
in the direction of the alveolar process, in which case it will be suffi- 
cient to take out the morbid growth from the inside of the antrum, 
and remove with it the portion of the alveolar process from which it 
has arisen. 

When the disease consists in hypertrophy of the maxillary bone, it 
may happen, as in the instance which ' will presently be related, that, 
in the most careful investigation of the case, no other enlargement of 
the bone can be discovered than that of its nasal portion, occasioning 
a prominence at the inner corner of the orbit, and a projection into the 
nostril ; yet, the osseous growth may have completely filled the antrum, 
and extended through every other part of the maxillary bone. Again, 
it should be remembered, that this particular disease, namely, hyper- 
trophy, is very apt not only to pervade the entire maxillary bone, but, 
besides, to extend into the adjacent bones of the same side of the 
face, and into the bones of the opposite side : of this there are exam- 
ples in the museums of the College of Surgeons and of St. Bartholo- 
mew's Hospital. 

A yielding or enlargement of the walls of the antrum, in one or 
other direction, is the indication of its cavity being filled by a morbid 
growth. But this indication may be wanting. In the museum of St. 
Bartholomew's Hospital there is an example of osseous exostosis filling 
both the antra, without yielding of the walls, or enlargement of either 
cavity. 

Such are the considerations which the surgeon should bring to the 
question, whether, in the case before him, a portion, or the whole, of 
the superior maxillary bone ought to be removed. And this is really 
no mean question, for it will, indeed, be an immense gain to the com- 

20* 



234 MORBID GROWTHS 

fort of the patient, if the circumstances of the case will allow the 
removal of part of the maxillary bone in a direction not to interfere 
with its palatine and alveolar processes, and thereby not to extend the 
incisions and removal of parts into the cavity of the mouth ; or, if the 
upper wall of the antrum can safely be left, so as not to interfere with 
the orbit. 

When the disease is limited to the nasal portion of the maxillary 
bone, the incision of the soft parts for its removal should be made 
along the bridge of the nose and through the middle of the upper lip. 
Then, by dividing the mucous membrane, along the line of its reflexion, 
from the cheek to the gum, and detaching the muscles from the bone, 
a flap of integument, comprising half the nose, half the upper lip, 
with the cheek, can be turned upwards to the margin of the orbit, 
giving the operator a full view of the interior of the nostril, and of the 
front surface of the maxillary bone. 

When, from the extent of the disease, it is necessary to remove the 
entire maxillary bone, the vertical incision, either along the bridge of 
the nose, or by the side of the nose, through its ala and the upper lip, 
will be insufficient. A second incision will be necessary, extending 
from the corner of the mouth, upwards and outwards, to the promi- 
nence of the os malae. This incision will be requisite for the division 
of the os malae, in the line where generally it should be made, immedi- 
ately behind the suture uniting it to the maxillary bone ; and, in in- 
stances where the disease extends into the os malee, this incision must 
be continued horizontally outwards upon the zygoma, in order that the 
division of the os malse may be made where it is perfectly sound. 

The following is another plan of the incisions for the removal of the 
superior maxillary bone, which, in particular cases, might be preferred. 
The vertical incision being first made by the side of the nose, and 
through the upper lip, a second incision is to extend from the lower 
edge of the ala nasi, obliquely upwards and outwards, in a line to- 
wards the middle of the cartilage of the ear, and to within about an 
inch of it. From the termination of this incision, a third is to extend 
directly upwards upon the zygoma. 

After the incisions of the integuments, the mucous membrane is to 
be divided horizontally in the line of its reflexion, from the cheek to 
the gum ; and the muscles, with the surrounding fat, are to be detach- 
ed from the front of the maxillary bone, in doing which, the infra- 
orbitar nerve will be divided at its exit from its foramen. The flap 
being turned upwards to the margin of the orbit, the contents of the 



FKOM THE JAWS. 235 

orbit are then to be separated from its floor, and here the infra-orbitar 
nerve will be again divided just before its entrance into its canal, and 
the inferior oblique muscle of the eye will be divided at its origin. 
Inattention to the complete division of the muscle would lead to its 
dragging upon the eye, when the maxillary bone is disturbed from its 
position. 

The principal incisions of the soft parts being completed, the divis- 
ions of the osseous connexions of the maxillary bone is then to be ef- 
fected. 

First, the os malge is to be divided close to the suture uniting it to 
cue maxillary bone, or further backwards if the disease extends into 
the os malse ; but, in either case, the division of the bone should be 
continued to the sphenomaxillary fissure ; for, unless this is done, the 
connexion of the maxillary bone will still be firm in this direction. 

Next, the alveolar process is to be divided through the socket of the 
front incisor tooth, which should be previously extracted, and the pal- 
ate is then to be divided close to the septum nasi, along the middle 
palatine suture ; and, unless it be impracticable from the extent of the 
disease, the palate should ^be divided transversely along the suture 
uniting the maxillary to the palate bone, thereby preserving entire the 
attachment of the soft palate. Previous to these divisions of the palate 
with the saw or cutting forceps, the palatine membrane should be di- 
vided with a scalpel. 

Lastly, the ascending portion of the maxillary bone is to be divided 
in a line extending from the upper part of the nostril to the inner 
corner of the orbit, thereby detaching the maxillary bone from the os 
nasi and from the internal angular process of the frontal bone. 

After the division of these several portions of bone, the principal 
remaining connexions of the maxillary bone will be at its back part 
with the pterygoid process of the sphenoid bone and with the soft pal- 
ate. The depression of the tumor, with, if necessary, some jerking 
movements of it, will loosen the connexion of the maxillary bone with 
the pterygoid process, and enable the operator to dislocate it, as it 
were, from its position ; and, in doing this, the orbitar plate of the 
maxillary bone will be detached from the os planum of the ethmoid. 
The only remaining connexion of the maxillary bone requiring division 
will be that with the soft palate ; and this must be carefully effected 
with the scalpel, especially if it has been found necessary to remove 
the entire bony arch of the palate, in order that the soft palate may 
be injured as little as possible in separating it from the palate bone. 



236 MORBID GROWTHS 

The several divisions of the maxillary bone require to be executed 
with the saw, cutting forceps, or strong scissors. Portions of bone 
which are readily divided with the scissors in early life, require the 
application of the saw in the adult. 

During the operation, the patient should be in the sitting posture, 
reclining but little, in order that the blood may escape through the out- 
ward wound, and not descend into the pharynx. 

The amount of haemorrhage from the parts divided in the operation, 
is not in general considerable. The internal maxillary artery of- 
ten becomes obliterated during the progress of the disease in the jaw ; 
if it should be open, the haemorrhage from it may be so profuse as 
to require the compression of the carotid. Usually, but few vessels 
require ligature. At all events, the preliminary step of tying the ex- 
ternal or common carotid is unnecessary. If much blood should flow 
from parts so deeply situated, that the divided vessels cannot be reach- 
ed with ligatures, the measures then to be taken are the maintenance 
of firm pressure for some time against the bleeding surface with dry 
lint, or with lint soaked in a saturated solution of alum ; and, if these 
fail, it might be deemed expedient to use the actual cautery. 

It has been considered necessary to fill the cavity of the wound with 
lint, for the support of the eye, and to prevent the cheek sinking in- 
wards ; this, however, was not done, in the cases which I have wit- 
nessed, and apparently no disadvantage ensued. Many fine sutures 
and thin pins are to be employed in maintaining the divided edges of 
the integuments in accurate contact ; and, over these, strips of isin- 
glass plaster are to be placed. 

If, in the removal of the maxillary bone, a portion of the parotid 
duct should be taken away, no salivary fistula may ensue, a new pas- 
sage being formed for the saliva into, the mouth. In removing a car- 
cinomatous tumor of the cheek, I took away, as it was implicated in 
the disease, half an inch of the terminal portion of the parotid duct ; 
yet no salivary fistula ensued : and, in the case of a naevus occupying 
the entire cheek, with the exception of the integuments, I removed the 
whole of the parotid duct to within half an inch of the gland ; yet 
there was afterwards no salivary fistula, and no evidence of obstruc- 
tion to the flow of the saliva into the mouth. 

The loss of the maxillary bone is followed by a less amount of dis- 
comfort and inconvenience than might be expected. Provided that 
the soft palate has been left entire, there will be but little impairment 
in the power of swallowing ; and articulation will be distinct, though 



FROM THE JAWS. 237 

with a change in the tone of the voice, from the loss of part of the 
bony arch of the palate. Mechanical contrivances may, in some de- 
gree, remedy this ; when but a small part of the arch of the palate has 
been removed, the adjustment of a silver plate, fixed with a sponge 
introduced into the opening, has, in some instances, restored to the 
voice its natural tone. 

The removal of the maxillary bone has been, in some instances, di- 
rectly fatal, apparently from the shock it occasioned to the system ; 
but there have been, I believe, more instances of its fatality, from 
erysipelas of the head and face, appearing after the healing of the 
divided edges of the integuments, but before the reparation of the 
large wound in the deeper parts of the face. It was my misfortune 
to have a case in the hospital which terminated unfavourably from this 
cause ; and I relate it, because there were circumstances of practical 
interest in it, with respect to the nature and diagnosis of the disease, 
and the operation performed for its removal. 

Hypertrophy of the Superior Maxillary Bone; removal. A girl, 
fifteen years of age, was admitted into St. Bartholomew's Hospital, 
with an oblong, hard, and painless enlargement of the nasal portion of 
the superior maxillary bone, projecting into the face and extending into 
the nostril : no disease was discoverable in the adjacent parts ; there 
was neither prominence of the cheek, nor displacement of the eye, nor 
projection of the palate. The patient and her father stated that the 
disease had been eight years in progress, and that it was still increas- 
ing. Her health was perfectly good. After she had been a few weeks 
in the hospital, it was evident that the swelling had increased since her 
admission, and, consequently, it became necessary to determine, if pos" 
sible, the nature and extent of the disease, in reference to the question 
of removing it by operation. The characters of the swelling indicated 
it to consist of solid osseous substance ; and from the extension of the 
disease into the nostril, I regarded the case as an instance of hypertro- 
phy of the maxillary bone ; but it was difficult to determine the boun- 
daries of the disease. There were no signs of its extension beyond 
the nasal portion of the bone ; but knowing the disposition of hyper- 
trophy of bone to spread widely and indefinitely, and knowing, besides, 
that although there was no enlargement of the antrum, it might never- 
theless be filled by osseous substance, I could not feel certain of the ex- 
tent of the disease, and, consequently, was unable to decide beforehand 
how much of the maxillary bone ought to be removed. 

In consultation, the removal of the diseased bone was agreed to be 



238 MORBID GROWTHS 

a right measure : but I was compelled to proceed to the operation with 
uncertainty on the two material points — the nature and extent of the 
disease. It was hinted to me that the swelling might be an osseous 
cyst, with thick sides ; this did not seem probable, as cysts are not apt 
to form in this part of the maxillary bone. However, to learn the na- 
ture of the disease, I commenced the operation by making a small in- 
cision of the integuments covering the most prominent part of the tu- 
mor, and then penetrated it with a perforator, by which I satisfied my- 
self that the tumor consisted of solid bone. Then, in the supposition 
that only the nasal portion of the maxillary bone might require remov- 
al, I made an incision along the bridge of the nose, in its whole length, 
and through the middle of the upper lip, and turned upwards the flap 
thus formed, comprising the ala nasi, and half the upper lip, with the 
cheek. My next object was to ascertain the condition of the antrum, 
and, accordingly, I perforated its front wall, by which I satisfied 
myself that its cavity was filled by solid bone. Under these circum- 
stances, there could be no hesitation respecting the necessity of remov- 
ing the entire maxillary bone, which was accomplished with the aid of a 
second incision of the integuments, extending from the corner of the 
mouth to the prominence of the os malae. 

The haemorrhage, during the operation and after it, was only from 
small arteries, which were readily secured. 

Scarcely any constitutional disturbance followed the operation. On 
the fourth day after it the pins and sutures being removed, the incis- 
ions of the integuments through their whole extent were found to be 
perfectly united. On the sixth day, erysipelas appeared in the oppo- 
site side of the face, and gradually spread upon the head and neck. 
Every effort was made to sustain the vital powers, but the erysipelatous 
skin became of a dusky red colour, and the circulation gradually sink- 
ing, the patient died on the tenth day from the operation. 

The part which had been removed comprised the entire superior 
maxillary bone, with the palatine portion of the palate bone, from which 
the soft palate had been carefully detached. The disease was hypertro- 
phy of the maxillary bone, pervading every part of it, and producing 
complete obliteration of the cavity of the antrum. Accordingly, the 
diseased part, when divided with a saw, presented no other character 
than that of a solid mass of bone. 



FROM THE JAWS. 239 



OF MEMBRANOUS CYSTS, CONNECTED WITH THE ALVEOLAR PROCESS 
OF THE UPPER JAW. 

Membranous cysts, apparently growing from the fangs of the teeth, 
are formed within the upper jaw, just above the alveolar process. 
These cysts, in enlarging, cause either an expansion and thinning of the 
walls of the bone, or the absorption of its outer wall, so as to appear 
on the outside of the jaw ; and in either case, the tumor projecting in 
the cheek, or into the mouth, may resemble the enlargement of the an- 
trum. Delpech relates an instance of this kind, in which the tumor 
was opened, and three ounces of fluid discharged from it. But he ob- 
served that the inside of the cavity, which contained the fluid, bore no 
resemblance to the inside of the antrum, and, accordingly, concluded 
it was an instance of a membranous cyst developed in the bone*. The 
following case, of the same kind, occurred, under the care of Mr. Law- 
rence, in St. Bartholomew's Hospital. A man, aged thirty-two, was 
admitted with a tumor in the face, which projected in the situation of 
the front wall of the antrum ; also downwards, between the cheek and 
the alveolar process, pushing the mucous membrane before it. A punc- 
ture was made into it, between the cheek and the jaw, when about a 
table-spoonful of glairy fluid, with solid shining particles floating in it, 
was discharged. A probe, introduced into the opening, could be mov- 
ed freely in the cavity from which the fluid flowed ; but it was doubtful 
whether this was the interior of the antrum, or a cavity contiguous to 
it. The tumor subsided, and there appeared to be no re-accumulation 
of fluid in it. 

The membrane, composing these cysts, is thick, of a white 'colour, 
and somewhat villous on its free surface. Their contents are either a 
fluid, thin, serous, and colourless, or sanguineous, or thick and muci- 
laginous, or a solid but soft and yellow substance : and, in some instan- 
ces, shining, spermaceti-like particles, are mixed with the fluid contents 
of the cyst. Generally there is only one cyst ; occasionally there are 
several. The cyst, in some cases, remains stationary while still of small 
size ; but in others, it increases, and it has acquired the dimensions of 
a large orange. 

* Elle ne presentait dans le bas, rien tie comparable a la raimire large que Ton ap- 
pelle la paroi inferieure du sinus maxillaire, rien en haut, qui repondit au plancher de 
l'orbite, rien en dedans, qui peut etre pris pour la paroi interne du sinus. II est evident 
qu'un kyste sero-muqueux s'est de'veloppe dans l'e'paisseur de la paroi inferieure du si- 
nus maxillaire. — Delpech, Ckirurgie Glinique de Montpellier. 



240 MORBID GROWTHS 

These membranous cysts are generally formed in early life, but oc- 
casionally at a later period. In some cases they are apparently the 
consequence of external injury, but, in general, they appear to have 
been consequent on the irritation of a carious, or misplaced tooth. 
And, from the observations which have been made on this subject, it 
appears probable that the development of the membranous cyst com- 
mences either close to, or actually within, the socket of a tooth, and 
near to the extremity of the fang. With reference to this point, Del- 
pech states, that he has witnessed cases where a sound tooth, being ex- 
tracted on account of severe pain in it, a small membranous sac, contain- 
ing a fluid, was found connected with the vessels and nerve of the 
tooth, at the extremity of its fang ; this sac having been lodged in a 
cavity of the bone at the bottom of the alveolus*. It may be doubted, 
however, whether these were not instances of abscess formed at the 
root of the tooth. 

When the membranous cyst, as it enlarges, causes an expansion of 
the bone, accompanied by the thinning of its walls, an osseous cyst is 
formed, the sides of which, being thin, readily yield to compression, 
and recoil, by their elasticity, with the peculiar crackling, or crepitat- 
ing sensation which generally belongs to osseous cysts with thin parie- 
tes, whether of new formation, or resulting from the expansion of the 
walls of the bone. 

In the treatment of these membranous cysts in the upper jaw, one 
or other of the following measures is to be preferred, according to the 
circumstances of the case, — the puncture of the swelling to ascertain 
the nature of its contents, — a free incision into the cyst, or the remov- 
al of a portion of it, that there may be a free outlet for its contents, 
— the injection of an astringent, or stimulant liquid, into the cyst, 
which will alter the character of its secretion, or which may induce 
suppuration within it, followed by the gradual contraction of it,— the 
application of escharotics to the inside of the cyst, which will destroy 
its lining membrane, and may be followed by the production of granu- 
lations from the inside of the cavity in the bone to the extent of com- 
pletely filling itf. In some instances, even where the cyst is large, the 
measure of affording a constant and free outlet for its contents is suffi- 
cient, the cavity in the bone then becoming obliterated, aud its expand- 

* Loc. cit. 

f Cases of the membranous cj r st within the jaw, which were successfully treated by 
the above measures, are reported in the Lecons Orales of M. Dupuytren, t. iii. ; also by 
Mr. Syme, Clinical Keport, Edinburgh Surg. Journ., July, 1835. 



FROM THE JAWS. 241 

ed walls returning to their natural condition. A sufficient opening into 
the cyst, for the free discharge of its contents, has been obtained by 
the extraction of a tooth and the perforation of the bottom of its sock- 
et. The opening into the cyst should always be made from the inside 
of the mouth. 

TREATMENT OF ACCUMULATIONS OF FLUID WITHIN THE ANTRUM. 

The character of the fluid, which, under different circumstances, is 
accumulated within the antrum, varies ; it may be puriform, or thin and 
serous, transparent, and of a yellow colour ; or it may have the char- 
acters of glairy mucus. Suppuration in the antrum may be the conse? 
quence of a blow on the cheek, but its more frequent cause is the irri- 
tation of a decayed molar, or bicuspid, tooth ; occasionally, however^, 
it has arisen without obvious cause. The best evidence of suppuratiom 
within the antrum, hi addition to the uneasiness and tenderness in thet 
cheek and adjacent parts, is the flow of matter into the nose, or through 
the socket of a recently-extracted tooth. 

The treatment of suppuration in the antrum consists in the forma- 
tion and maintenance of a dependent opening in the cavity, and in oc- 
casionally syringing it with tepid water. A small metallic syringe, 
with its pipe a little curved, is well suited for this purpose. The de- 
pendent opening is conveniently made through the socket of a molar, 
or bicuspid, tooth. If the extraction of a tooth is necessary, the first 
or second molar should be preferred. But the opening into the an- 
trum can be as well made by the perforation of its front wall. Having 
divided the mucous membrane and periosteum, just above the first or 
second molar tooth, the wall of the antrum may then be easily perforat- 
ed ; and the aperture should be large, that the matter may readily es- 
cape through it, and that it may not speedily close. In perforating 
the front wall of the antrum, the other points of attention are, to make 
sufficient allowance for the depth of the alveolar process, which varies, 
and to direct the perforation obliquely upwards and inwards, that it 
may enter the cavity fairly above its lower boundary. If the opening 
in the antrum should appear to be closing before the secretion of mat- 
ter into it has ceased, a tent of linen, or lint, or a piece of an elastic 
gum catheter, should be introduced into it. The following cases, relat- 
ed in the Memoir of Bordenave*, are good illustrations of the subject ; 
they are interesting besides, as showing the perfect knowledge he pos- 

* Loc. clt. 

21 



242 MORBID GROWTHS FROM THE JAWS. 

sessed of the nature and treatment of these diseases : indeed, to his 
observations, recorded a century ago, but little importance has been ad- 
ded in modern times. 

" A young woman had a swelling on the cheek, preceded by acute 
pain, extending to the orbit, attended with a sense of heat and throb- 
bing in the part. These symptoms determined Bordenave to extract 
the third molar tooth*, and perforate the bottom of its socket. A large 
quantity of matter was discharged. The cavity of the antrum was in- 
jected, the swelling of the cheek subsided, and in six months the pa- 
tient was perfectly well. A child, twelve years of age, had caries of 
the first molar [bicuspid] tooth, and swelling of the cheek ensued. 
An accumulation of fluid in the antrum, from the irritation of the de- 
cayed tooth, was suspected. The tooth was extracted, and a large 
quantity of a yellow, watery fluid immediately escaped from the sock- 
et. The swell' ng of the cheek immediately subsided, and the patient, 
in a short time, was perfectly well." 

Cases are also related by Bordenave, of suppuration in the antrum, 
followed by ulceration of its front wall, and the formation of fistulous 
passages in the cheek, on account of which it became necessary to ex- 
tract one or two of the molar teeth, to obtain the constant discharge of 
the matter through the dependent opening. The fistulous openings in 
the cheek immediately closed. When the passage from the socket of a 
tooth into the antrum was disposed to close, before the suppuration in 
its cavity had ceased, Bordenave advised the patient to keep a silver 
canula in the opening. 

* The first molar in the modern classification of the teeth. 



CH A PTER II 



DISEASES OF THE BONES OF THE SPINE. 

It would be of little practical utility to consider the diseases of the 
bones of the spine apart from those of their appendant structures, the 
fibro-cartilages, ligaments, and periosteum ; accordingly, the subject 
of the following section will be the diseases of the entire vertebral 
column. 

Some of the diseases of the spine are of an inflammatory nature, 
simple or rheumatic ; others are of a scrofulous character, and com- 
bined with the deposition of tubercle in the bones and fibro-cartilages. 
There, also, occur in the spine, the malignant diseases carcinoma, ence- 
phaloma, melanosis. 

The following structural changes from inflammation occur in the 
spine — thickening of the periosteum and ligaments ; suppuration be- 
neath the periosteum, also within the bones ; ulceration, hardening, and 
necrosis of the bones ; softening and ulceration of the fibro-cartilages. 

Mechanical injury — such as a blow on the spine, or a sudden and 
forcible movement of the trunk wrenching the spinal ligaments, — or 
some special exposure of the body to cold and moisture, comprise the 
most frequent causes of inflammation in the coverings of the spine. 
Occasionally the spinal affection is associated with inflammation in one 
or more of the larger joints in the limbs. And, in some of these 
cases, paraplegia ensues by extension of the inflammatory action from 
the coverings of the spine to the spinal cord and its nerves, or by thick- 
ening of the posterior vertebral ligament, whereby the spinal canal is 
narrowed to the degree of compressing the cord*. 

More acute inflammation in the fibrous coverings of the spine occa- 
* C. A. Key, in Guy's Hospital Keports, Vol. iii. 



244 DISEASES OE THE BONES 

sions suppuration between the periosteum and the bones, and these 
cases are to be regarded as analogous to those of acute periostitis upon 
other bones. The following is a well-marked history of such a form of 
spina! disease. 

Suppuration beneath the coverings of the Spine. A healthy man, 
forty-five years of age, was exposed to frost and snow through a long 
winter's night. A few days afterwards he was attacked with smarting 
pain in his back, a sensation he said like that of boiling water flowing 
over the skin. This lasted a fortnight, and was followed by a more se- 
vere pain, making him feel as if he was lying on sharp cutting flints. 
These were the symptoms preceding suppuration between the spine and 
its coverings. The pain gradually subsided, and was succeeded by 
slowly-increasing paraplegia. In about fourteen months from the com- 
mencement of the disease he died. On examining the spine, I found 
a large quantity of purulent fluid between the periosteum and the 
bodies of the fifth, sixth, and seventh dorsal vertebrae. The purulent 
fluid accumulated upon the posterior surfaces of these vertebrae, al- 
though confined by the periosteum and posterior vertebral ligament, 
yet projected into the spinal canal sufficiently to compress the cord. 
The surfaces of the vertebrae, with which the purulent fluid had been in 
contact, were roughened, and their fibro-cartilages had disappeared*. 

I have known instances where, in the course of fever, acute inflam- 
mation has arisen in the bones of the spine, occasioning excessive vas- 
cularity of their cancellous texture, with destruction of the fibro-carti- 
lages, apparently by mortification and sloughing of their tissue. 

Purulent fluid is often found diffused through the cancellous texture 
of the vertebrae ; but I have not known any certain example of cir- 
cumscribed abscess in a vertebra similar to that which occurs within 
the articular ends of long bones. There is, however, in the museum 
of St. Bartholomew's Hospital, a lumbar vertebra, hollowed out in the 
centre of its body into a round cavity, which communicates by a small 
opening with the spinal canal. It is not unlikely, that this vertebra had 
been the seat of circumscribed abscess, which burst into the spinal ca- 



=fc Louis has recorded cases in which impaired motion and sensation in the limbs en- 
sued from compression of the cord by purulent fluid accumulated within its bony canal. 
Memoires ou Kecherches Anatomico-Pathologiques — De l'e'tat de la moelle epinale 
dans la carie vertebrale. 



OF THE SPINE. 245 

nal just as the abscess within the articular end of a bone often bursts 
into the adjacent joint. 

Ulceration of the bones of the spine is the most frequent of their 
structural changes ; and, in some instances, hardening of the inflamed 
bone precedes its ulceration. Ulceration occurs most frequently in the 
bodies of the vertebrae ; occasionally it attacks their arches and pro- 
cesses. In some instances, ulceration appears to have attacked many 
vertebrae, and, in others, several parts of a vertebra at the same time. 

Mechanical injury is probably the most frequent cause of ulceration 
of the vertebrae. The following are instances of its occurrence from 
this cause. 

Ulceration of the Vertebrce from injury. A man fell on his back 
into the hold of a ship. Severe pain ensued in the lower part of the 
spine, with feebleness of the lower limbs. Seven months afterwards he 
died. On examining the spine, I found numerous ulcerated cavities in 
the bodies of the twelfth dorsal, and of all the lumbar vertebrae, with 
much serum in the theca of the cord. 

Ulceration of the Vertebrce from injury. A middle-aged man, 
whilst holding a ladder which he had raised from the ground, was turn- 
ed sharply round by a gust of wind. From that instant he felt pain in 
his back, which continued ; and, in the course of the following six 
months, angular projection of the spinous processes of the middle dor- 
sal vertebrae ensued, with complete loss of motion and sensation in the 
lower limbs. He gradually sank. On examining the spine, I found 
the bodies of three of the dorsal vertebrae extensively ulcerated, and a 
detached piece of the middle of these vertebrae displaced backwards 
into the spinal canal, and compressing the cord. 

Ulceration of the vertebrae is, in most instances, accompanied by fix- 
ed pain in the diseased part ; but occasionally it is otherwise, and then 
the disease advances without signs of its existence, until it is made evi- 
dent, either by the distortion consequent on the destruction of the bo- 
dies, or by some change in the direction of the spinous processes con- 
sequent on the destruction of the arches, of the vertebrae. 

Ulceration of the bodies of the vertebrae usually commences in their 
anterior parts, and it rarely extends completely through them. But 
even upon this incomplete destruction of the bodies of the vertebrae, 
paraplegia occasionally ensues of the worst kind, as it is caused by 
compression of the spinal cord. The following is the mode of its oc- 
currence. After the destruction of the front parts of the bodies of a 

21* 



246 DISEASES OF THE BONES 

certain number of the vertebrae, the healthy vertebral bodies bounding 
the seat of the disease, gradually approximate, and, in doing so, they 
force backwards the posterior parts of the bodies of the ulcerated ver- 
tebras ; thus the spinal canal becomes narrowed and the cord com- 
pressed ; or, as in the case just related, a detached piece of the dis- 
eased bone, forced backwards into the spinal canal, compresses the 
cord. With the knowledge of these facts, I have been able to form a 
definite opinion of the nature of the disease, and of its probable result, 
in cases where, with unnatural projection of the spinous processes, 
complete paraplegia occurred at an advanced period ; ' and, in several 
of these, the examination of the parts after death verified the opinion, 
showing the disease to have been ulceration of the vertebrae, with dis- 
placement of the diseased bone, and compression of the spinal cord. 

Ulceration of the vertebrae is reparable only to a limited extent. 
The ulcerated hollows in the bones become filled with fibro-cellular 
tissue ; but the lost bone is never reproduced, and, accordingly, when 
the bodies of the vertebrae are extensively ulcerated, the process of 
cure consists in the approximation and union of the opposite surfaces 
of the healthy vertebrae bounding the seat of the disease. 

It has been a question, whether disease ever commences in the 
inter-vertebral fibro-cartilages ; but it is proved to do so in instances 
where the fibro-cartilages are found diseased, and the adjacent bones 
sound. In the body of a young man, from whose thighs two psoas 
abscesses had long been discharging, I found no trace of either psoas 
muscle, the place of each muscle being occupied by the cyst of a large 
abscess ; both abscesses communicated above with a space between 
the bodies of the third and fourth lumbar vertebrae, resulting from the 
destruction of the intervening fibro-cartilage ; but the adjacent bones 
and the rest of the fibro-cartilages were perfectly sound. 

The disease which begins in a fibro-cartilage appears to be inflam- 
matory, occasioning, first, in the softening, and then the splitting of its 
tissue into shreds; in this way the fibro-cartilage gradually disap- 
pears, and, whilst these changes in the fibro-cartilage are in progress, 
the adjacent bones become affected in a manner to show the inflamma- 
tory character of the disease ; their cancellous texture becomes har- 
dened, and then it ulcerates. Such, therefore, is the condition in 
which the vertebral bodies are usually found adjacent to the vacant 
space between them, resulting from the destruction of a fibro-cartilage. 

The disease just described, in many instances, attacks only a single 



OF THE SPINE. 247 

fibro-cartilage ; but it often attacks several of them, and there have 
been instances of its occurrence through the whole series of the fibro- 
cartilages, from the second cervical vertebra to the sacrum*. One 
other circumstance belongs to the history of this disease in the inter- 
vertebral fibro-cartilages, namely, that it often gives rise to the for- 
mation of psoas abscess. It has certainly been so in many instances 
which I have examined ; in some of them there was a single, and in 
others a double psoas abscess, the two abscesses communicating with 
the vacant spaces between the vertebral bodies resulting from the de- 
struction of the fibro-cartilages ; and, in many of these, only a single 
iibro-cartilage had been diseased. 

There are instances of the deposition of tubercle in the inter-verte- 
bral fibro-cartilages, independent of disease in the bones. In one such 
case, where the cause of death was the deposit of tubercle in the 
cerebellum, tubercular deposits were found in several of the lumbar 
inter-vertebral fibro-cartilages ; but there were none in the vertebrae 
themselves. 

Scrofulous disease exhibits the same characters in the bones of the 
spine that it does in other bones. The vertebrae become soft by dim- 
inution of their earthy constituents, and tuberculous matter is diffused 
through their cells. Whilst these changes are going on in the bones, 
tuberculous matter is often deposited in large quantity upon the front 
of the spine, beneath its fibrous coverings ; and, in some instances, 
these coverings yield in such a manner, that the accumulated tubercu- 
lous matter forms a solid circumscribed tumor, projecting forwards 
into the cavity, either of the chest or abdomen. When this tumor is 
of large size, and projects forwards into the abdomen, it may be felt 
through the parietes ; and I have known instances of its being mis- 
taken for the swelling of enlarged absorbent glands, or of malignant 
disease. 

When the bodies of the vertebrae are softened and their cells filled 
with tuberculous matter, the reparative process which may ensue con- 
sists in the removal of the diseased bones, and in the approximation 
and union of the healthy vertebrae above and below them. But in 
consequence of the disease extending through the entire thickness of 
the vertebral bodies, the subsequent approximation of the healthy 

* Museum of St. Bartholomew's Hospital, Fourth series, No. 37, Plate 21, fig. 1 



248 DISEASES OF THE BONES 

vertebrae, with- the accompanying projection of the spinous processes, 
does not occasion any narrowing of the spinal canal. So far from this 
being the result, the canal is actually widened by the removal of the 
posterior parts of the bodies of the diseased vertebrae. 

The foregoing facts accord with the progress of the symptoms in 
scrofulous disease of the spine. Thus, in its early stage, impaired mo- 
tion and sensation of the limbs often ensue from the irritation of the 
diseased bones communicated to the spinal cord and its nerves. But, 
in the more advanced stage, when, from the projection of the spinous 
processes, it is evident that the bodies of the diseased vertebrae have 
been removed, yet there is no increase of the paraplegia. Indeed, at 
this period, the feebleness, twitchings, and painful spasms of the limbs 
usually subside, the spinal cord suffering no impairment of its func- 
tions, as it has become adapted to the bony canal changed in its di- 
rection, but widened at the seat of the disease. In these particulars, 
scrofulous disease of the spine contrasts remarkably with the results of 
simple ulceration of the bodies of the vertebrae, when, in the advanced 
stage of the disease, complete and irremediable paraplegia ensues 
from the compression of the spinal cord by the displaced bones. 

It should be known, as it leads to proper caution in the treatment, 
that scrofulous disease in the spine is apt to recur in the same part of 
the spine at a distant period after apparent recovery. I have seen 
cases wherein, several years after the apparently perfect cure of 
scrofulous disease in the vertebrae, it relapsed ; and, in most of these 
cases, psoas abscess appeared on the occasion of the second attack of 
disease in the spine. 

DISTORTIONS OF THE SPINE ENSUING FROM DISEASE OF THE BONES 
AND FIBRO-CARTILAGES. 

Whatever irregularity or distortion ensues in the spine during or 
after ulcerative disease, is owing to the mode of its reparation, without 
reproduction of the bone that has been destroyed. Thus the angular 
projection of the spinous processes and arches is consequent on the de- 
struction of the bodies of the vertebrae. So the destruction of the 
arches of the vertebrae is followed by the sinking of their spinous pro- 
cesses. Accordingly, the evidence of disease in the vertebral arches 
is the occurrence of a depression or hollow in the spine, from the sink- 
ing of one or more of the spinous processes, whilst an increase in the 
inter-spaces of the spinous processes is an indication of the destruction 



OP THE SPINE. 249 

or yielding of the ligaments which unite them. It must, however, be 
observed, that irregularities in the length, thickness, figure, or direc- 
tion of the spinous processes in any region of the spine, are not of 
themselves, independently of other considerations, sure evidence of 
disease, as such deviations are occasionally met with in the original 
conformation of the spine. In the dorsal and lumbar vertebrae more 
especially, I have seen instances of the spinous processes inclining con- 
siderably from their regular line to one or other side. Also, in the 
cervical vertebrae, I have seen the spinous processes from original for- 
mation twisted obliquely to one side. 

Destruction of the bodies of the cervical vertebrae, followed by con- 
solidation of the adjacent healthy vertebral bodies, is accompanied by 
shortening of the neck, with an arched projection of the spinous pro- 
cesses. The head approximated to the shoulders is inclined forwards, 
and is stiffly held in this position, in consequence of the restraint in the 
movements of the neck. 

Destruction of the bodies of the dorsal vertebrae, followed by con- 
solidation of the adjacent healthy vertebrae, is accompanied by angu- 
lar projection of the spinous processes. When, however, as sometimes 
happens, the upper and lower surfaces of the bodies of several dorsal 
vertebrae are extensively destroyed, this portion of the spine will be- 
come bent forwards, with an arching of the spinous processes. There 
are, also, instances of disease destroying only one side of the bodies 
of several dorsal vertebrae, occasioning a lateral inclination of this por- 
tion of the spine, and thus adding lateral curvature to the angular 
projection of the spinous processes ; and there are cases where ulce- 
ration of the vertebral bodies had extended completely through them, 
but so much more widely and deeply on one side, that the reparative 
process was accompanied by a lateral angular distortion of this portion 
of the spine. 

It is worthy of note, that after the destruction of so large a portion 
of the spine as is comprised by the bodies of eight of the dorsal ver- 
tebrae, with no reproduction of the lost bone — and notwithstanding the 
extreme angular distortion which ensues — yet this part of the column 
may again be made firm and strong, by the osseous union of the op- 
posite surfaces of the adjacent healthy vertebrae, aided by the forma- 
tion of osseous bridges extending over the front and lateral surfaces of 
their bodies. 

Destruction of a large portion of one or two of the bodies of the lum- 
bar vertebrae, is followed by the angular projection of their spinous 



250 DISEASES OF THE BONES 

processes ; but, from the destruction of a small portion of the bodies of 
several of the lumbar vertebrae, an arching of their spinous processes 
ensues. 

In instances where a single inter-vertebral fibro-cartilage has been 
destroyed without disease in the adjacent bones, the reparative process 
is not accompanied by deformity. The adjacent vertebral bodies do 
not then approximate, but become firmly connected together, and fixed 
in their position by bridges of osseous substance extending over their 
front and lateral surfaces. In one case, even after the destruction of the 
fibro-carfcilages of three dorsal vertebrae, no approximation of the adja- 
cent vertebral bodies ensued ; they became firmly fixed by osseous 
bridges extending over their front and lateral surfaces, and, consequent- 
ly, there was no perceptible change in the figure of the spine. When 
a still larger number of inter-vertebral fibro-cartilages is destroyed, the 
consequent deformity will be an arching of the diseased portion of the 
spine. The segment of a circle, which the spine then forms, has led 
to the erroneous supposition of its distortion being an effect of the 
simple yielding of its ligaments from weakness. 

GENERAL REMARKS ON THE SYMPTOMS OF DISEASE IN THE SPINE. 

Question of Pain in the Spine, being the evidence of disease in it. 
The reply of experience will be, that pain in the spine is not sure evi- 
dence of disease in it ; nor is the absence of pain sufficient proof of the 
soundness of its structures. The many acknowledged sources of ten- 
derness in the spine forbid the conclusion, in any case, that, independ- 
ently of other circumstances, it must be the effect of organic disease . 
And the absence of pain in the spine is no proof of the soundness of 
structures, since disease is here often observed running its course to 
destruction of the parts it has attacked without an uneasy feeling in 
them. But, notwithstanding its always doubtful character, pain in the 
spine, if persistent, limited to a small district, and not yielding to 
treatment, is a symptom not to be disregarded. I have known instan- 
ces of attacks of pain in the lower part of the spine confidently treat- 
ed as lumbago, which proved to be the precursor of complete and per- 
manent paraplegia, from disease in the spinal cord. And I have, also, 
known lumbago, which proved to be the accompaniment of destructive 
disease in the vertebrae. 

It is remarkable for how long a time, in some cases, pain will endure 
in the spine, whether or not accompanied by irritation of the spinal cord 



OF THE SPINE. 251 

and nerves, before the other symptoms appear, significant of disease 
in the vertebras. In one case which I saw, there had been pain in the 
spine, with intermissions, for ten years, when disease in the vertebrae 
was at length made evident, by perceptible change in the position of 
the spinous processes. 

Pain limited to a small district of the spine, of the same character 
as that which belongs to disease in the vertebrae, is often the first, and 
continuing symptom of disease in the spinal cord ; and hence, the ob- 
scurity in the diagnosis of these affections is, in some cases, so great, 
that the treatment throughout is conducted with uncertainty, whether 
the disease be in the vertebrae, or in the cord. 

How much caution should be observed in deciding upon the signifi- 
cance of pain and tenderness in the spine, even when long persistent, 
and fixed in a small district of it, is to be learned from cases, such as 
I have known, where the pain in the spine of this character had been, 
for many months, treated with confidence of success, and by means 
wholly unsuited to the real nature of the disease, which proved to be 
an aneurism, making its way through the bodies of the vertebrae. 

Here it may be well to advert to the not infrequent instances of 
scrofulous disease in the spine advanced to the stage of destruction of 
the softened vertebral bodies, with the accompanying angular projec- 
tion of the spinous processes, but throughout unattended by a single 
symptom, local or constitutional, that had given warning of the exis- 
tence of the disease. It has several times happened to me, as it must 
have done to others, to be told, that in a child, apparently in perfect 
health, the discovery had, by accident, been made of a projection of 
one of the spinous processes, so marked as to permit no doubt on the 
point of one or more of the softened vertebral bodies being crushed, 
and, perhaps, wholly removed. It is, moreover, remarkable, how fre- 
quently such examples of scrofulous disease in the spine occur in 
children, whose systems have not been debilitated by any of the infan- 
tile diseases, such as measles, or scarlatina, whose position in life, be- 
sides, has been such that they have not suffered from deficient food, 
impure air, or bad clothing ; or, indeed, from the operation of any of 
the causes to which the production of scrofulous disease in the spine is 
usually ascribed. 

Symptoms of Affection of the Spinal Cord and Nerves, ensuing 
from Disease in the Spine. According to the mode of action of dis- 
ease in the spine, by irritating the spinal cord, or by compressing the 
cord to the degree of annihilating its functions, the nervous symptoms 



252 DISEASES OF THE BONES 

are, twitches, or painful spasms, or numbness, or annihilation of the 
motive, or sensitive, power, or of both, in the parts receiving the spinal 
nerves. Mostly the motive power is impaired in a greater degree than 
sensation, probablj from the proximity of the motor nerves and col- 
umns of the cord to the vertebral bodies and fibro-cartilages, which are 
generally the seat of disease. 

Other modifications in the nervous affection are occasionally observ- 
ed ; thus the irritation of the spinal cord, instead of taking its usual 
course downwards, and affecting the parts below the disease, has, in 
rare cases, travelled upwards, so that disease in the lower dorsal verte- 
brae has chiefly affected the nerves of the upper limbs. The internal 
organs, especially of the abdomen and pelvis, variously participate in 
the nervous derangements ensuing from disease in the spine, and mani- 
fest, either a slowness of their action, or an apparent increase of their 
sensibility ; the latter more particularly occurring in the mucous sur- 
faces of the bladder and intestines, which, in some cases, become so 
susceptible of slight impressions, that the mere touch of the inside of 
the bladder by a catheter, or the slight stimulation of the intestines by 
a purgative, will be directly followed by severe spasms in the limbs. 

There are cases of disease in the spine, wherein the nervous de- 
rangement is wholly manifested in the trunk by the following symp- 
toms : — a sense of tightness and constriction across the upper part of 
the abdomen, uneasy breathing, a sense of distension in the lower part 
of the abdomen, with enfeebled action of the intestines, and of the 
bladder ; and so the symptoms have continued for months before the 
appearance of direct evidence of disease in the spine. 

In some cases, the impaired nervous functions in the limbs had ex- 
isted for many months before the evidence arose of their being caused 
by disease in the spine. In one such case which I saw, feebleness, 
with cramps and twitches in the lower limbs, had endured for eighteen 
months before the disease, which had been going on in the spine, was 
made evident by a projection of the spinous processes of one of the 
lumbar vertebrae. 

The derangements in the functions of the spinal cord and its nerves 
which arise from disease in the spine, are also precisely the derange- 
ments which ensue from disease in the cord itself. Hence the difficul- 
ty so often experienced in determining the source of the nervous de- 
rangement, whether, if not depending on disease in the spine, its source 
be mischief in the brain, or in the spinal cord, or in its nerves ; for, in 
the same way that a current of cold air directed against the face oc- 



OF THE SPINE. 253 

casions congestion, or inflammation of the portio dura, and, in conse- 
quence, paralysis of the facial muscles, so have cold and moisture di- 
rected to the loins affected the lumbar and sacral nerves, occasioning 
cramps and numbness of the limbs, such as ensue from disease in the 
spinal cord. Or, it may be, that the nervous symptoms present in any 
case, without direct evidence of disease in the spine, may constitute 
that variety of paraplegia which occurs coincidently with disease of 
some internal organ, either in the chest, abdomen, or pelvis, and is un- 
accompanied by organic change, either in the spinal cord, or its nerves. 

TREATMENT OF DISEASE IN THE SPINE. 

One rule of treatment belongs to all diseases of the spine ; namely,, 
to keep the diseased parts at rest, and to remove from them all weight 
and pressure by observance of the horizontal posture. And when ul- 
cerative disease is seated as it is almost constantly, in the bodies of the 
vertebrae, no restraint of position is to be imposed that can impede the' 
approximation of the healthy vertebrae bounding the seat of the disease,, 
as this would be to put an obstacle in the way of the only process of 
cure of which the disease is susceptible. 

Local depletion, by cupping or leeching the tender part, of the spine, 
is only in some cases an available remedy. The abstraction of blood 
will, it is true, often remove the tenderness of the spine, but it will 
quickly recur ; and the objection to a large amount of depletion is, that 
it takes from the system the strength which will be wanted for its 
support through a slowly progressing disease. Still, however, in the 
uncertainty that so often attends the symptoms, of spinal disease, local 
depletion is not to be laid aside as an inappropriate remedy for these 
symptoms in an early stage of the complaint, when it may be uncertain 
whether their cause resides in the spine, or in the spinal cord. To in- 
stance a case which I have seen. Paraplegia, accompanied by tender- 
ness in a small district of the spine, occurred from no obvious cause. 
Disease in the vertebrae was consequently apprehended. But local de- 
pletion, freely employed, so speedily and completely removed the para- 
plegia, as to permit no other supposition of its cause than that it was a 
preternatural afflux of blood to the vessels of the spinal cord. Cau- 
tion is, however, required in the employ of local depletion ; for, in in- 
stances where it has not been at once a remedy for an incipient para- 
plegia, the repetition of it has been followed by increased failure of 
nervous power, both motive and sensitive, in the limbs. 

22 



254 DISEASES OF THE BONES 

Mercury is a remedy for acute inflammatory affections of both the 
spine and the spinal cord, especially for such as are the consequence 
of mechanical injury. In the following case of this kind, the beneficial 
effects of the mercurial treatment were well marked. 

Inflammation of the Spine and Cord from Injury. A young 
woman fell down stairs flat on her back. For several days afterwards, 
blood was mixed with the urine, and there ensued severe pain along 
the spine, also in the back of the head, with defective vision,, squinting, 
numbness, and convulsions in the upper and lower limbs, and fever. 
Under these circumstances, inflammation of the spinal cord, extending 
to the brain, appeared to be the disease, and mercury the remedy. 
Accordingly, calomel and opium were freely administered, and mercu- 
rial ointment was applied to the spine. Directly salivation was produc- 
ed, the subsidence of the pain in the spine, and of all the other symp- 
toms, was so marked, as hardly to warrant any other inference than 
that the mercury had stopped the progress of inflammation in the spi- 
nal cord, or its membranes. 

The mercurial treatment, it must, however, be admitted, is benefi- 
cial only in a limited proportion of spinal and paraplegic affections ; 
and this consideration, in reference to it, is always to be borne in mind 
— that when not directly of benefit, its tendency is to lower the vital 
powers, and whatever has this effect, is almost sure to increase the 
spinal complaint and the nervous symptoms associated with it. 

One other narrative it may be well to furnish, in illustration of the 
treatment required in cases of inflammation of the spine, implicating 
the spinal cord, directly consequent on mechanical injury. 

Inflammation of the Spine and Cord from Injury. A man, aged 
twenty-one, whilst carrying a basket of vegetables on his head, was 
knocked down and fell on his back. He walked to the hospital, but 
was not retained there, as the only discoverable injury was a slight 
bruise of his knee. In returning home, he fell six or seven times, be- 
cause, as he said, his legs gave away under him. By the next morn- 
ing he had wholly lost the use of his lower limbs, and was, consequent- 
ly, conveyed again to the hospital. The motor power in the limbs was 
wholly lost, but the sensation in them was preternaturally acute. The 
spine was extremely tender in its whole extent, and there was, besides, 
retention of the urine. The skin generally over the body was hot and 
dry, the pulse full and sharp. Ten ounces of blood were removed by 
cupping from the spine, and afterwards twelve ounces of blood were 
taken from the arm. Saline medicine, with antimony and hydrargyrum 



OF THE SPINE. 255 

cum creta, was freely administered, and due attention was paid to the 
state of the bladder, the urine being very acid, and so loaded with mu- 
cus that it flowed with difficulty through the catheter. To prevent the 
lodgment of mucus in the bladder, it was daily washed out with tepid 
water, by means of a double-tubed catheter. The gums became sore, 
and they were kept so by the continued administration of mercury. 
By the twenty-seventh day, the bladder had recovered its power ; as 
yet, however, there was no improvement in the limbs. But from this 
period, their motor power gradually returned ; so that, at the end of 
two months, the man was discharged from the hospital, walking well, 
and in every respect restored to health. 

In cases which are presumed, from their history, to be examples of 
rheumatic inflammation of the investments of the spine, iodide of po- 
tassium in the chronic form of the disease, and calomel with opium and 
antimony in its acute form, are the suitable, and, in many instances, 
successful remedies. 

There is another remedial agent applicable to certain paraplegic af- 
fections, such as seem to have had their origin in exposure to sudden 
and extreme variations of heat, cold, and moisture. Whether in these 
paraplegic affections, the spinal cord is affected primarily, or but sec- 
ondarily, from inflammation of the coverings of the spine, may be 
doubtful ; but the distinction is not of moment, if, for the relief of the 
paraplegic affection, however it has arisen, an effectual remedy can be 
administered. Such a remedy, in certain cases, is the bichloride of 
mercury, in doses of the sixteenth or twentieth of a grain twice or 
thrice a day, but continued for a long period, even for many months. 
Sir B. Brodie has been, I believe, long in the habit of employing this 
remedy in such cases. My attention was directed to it by Dr. La- 
tham, who stated to me, as the results of his experience of its use in 
all degrees and modifications of impaired nervous power to complete 
paraplegia, that, in many cases which had occurred under his observa- 
tion, there was every reason for believing that the bichloride of mercu- 
ry, given in combination with the tincture of bark, had been the means 
of effecting the complete restoration of the use of the limbs ; in other 
words, of curing the paraplegia. According to the circumstances of 
the case, Dr. Latham has been accustomed to direct the sixteenth or 
twentieth of a grain of the bichloride with a drachm of the tincture of 
bark twice or thrice daily ; in this way I have administered it, and cer- 
tainly with benefit. 

Among other cases in the hospital treated upon the foregoing plan, 
was the following. A man, aged twenty, had suffered from paraplegia 



256 DISEASES OF THE BONES 

for eight months, which, upon investigation, could be ascribed to no 
other cause than the exposure to alternations of heat and cold in his 
occupation as a blacksmith. With every advantage of rest in the hori- 
zontal posture, and attention to his general health, he had taken the 
sulphate of zinc in doses of two grains three times a day, first alone, 
and then with twenty minims of the tincture of cantharides, continu- 
ously for six weeks, but without any amendment. I then directed for 
him the sixteenth of a grain of the bichloride of mercury, with a 
drachm of the tincture of bark, three times a day. He had taken these 
remedies but a week, when he became sensible of improvement in the 
condition of his limbs. The improvement was steadily progressive. 
In about six weeks, he walked about the ward with ease and firmness. 
Before he commenced the use of the medicine, he could neither stand 
securely nor raise his legs from the ground. 

I would not state, that the remedies just mentioned are suited but to 
one class of cases of paraplegia, or that all belonging to this class will 
be cured by them ; but, looking to the fact of the many cases of para- 
plegia which admit of no relief, and to the many others which admit 
only of partial relief, and bearing in mind the impossibility of discrim- 
inating by their symptoms, the cases which are curable from those 
which are not, value must be attached to remedies which have been 
the means of cure in any number of cases, however small it may be. 
Dr. Burrows states to me his impression of the results of the treatment 
of paraplegia, to the effect, that mercury in one or other of its forms, 
is the remedy from which the largest amount of success can be obtain- 
ed ; but that when pushed to the extent of salivation, although it may 
produce a temporary amendment, it will sometimes, by its lowering ef- 
fects on the vital powers, cause a subsequent increase of the paraplegic 
symptoms. 

It is not intended to imply by the foregoing observations, that the 
sulphate of zinc is a powerless agent in paraplegia, for I know it is not 
so ; there are undoubted instances of its efficacy ; but these, as it has 
appeared to me, occurred in a class of cases where there had not been 
an inflammatory origin of the disease, such as has belonged to those 
examples of paraplegia for which mercury has proved an effective 
remedy. 

Upon the question of the utility of counter-irritation in diseases of 
the spine, much diversity of opinion exists. My impressions respect- 
ing it are of considerable do^bt, whether counter-irritation ever arrests 



OF THE SPINE. 257 

the progress of scrofulous disease in the vertebrae. But I have thought 
that, in other ulcerative diseases attacking the vertebrae, or their fibro- 
cartilages, counter-irritation, whilst alleviating the pain and tenderness 
in and around the diseased parts, has arrested the progress of the dis- 
ease. On another point I have no doubt, namely, that in scrofulous, 
as also in other diseases of the vertebrae, counter-irritation may be the 
means of withdrawing from the spinal cord and its nerves, the irritation 
to which the disease in the vertebrae has given rise. And this it often 
does immediately, and in the most marked way, by at once restoring to 
the patient the use of his limbs. So many clear instances of this re- 
sult of the treatment by issues have occurred within my own observa- 
tion, that I can entertain no doubt of the correctness of the view here 
stated respecting it. But the best evidence on this point is obtained 
from hospital practice ; for here the patients, on regaining the use of 
their limbs, frequently will submit to no further restraint ; they leave 
the hospital, and suffer the issues to close ; but, on again becoming un- 
able to walk, they return, soliciting the re-application of the issues. 
One patient I had who three times returned to the hospital to have the 
issues re-made, in the conviction of the benefit she had received from 
them. 

The following is a short history of one of the earliest of the cases 
of diseased spine in St. Bartholomew's Hospital, which Mr. Pott 
treated by issues. It occurred in the recollection of Mr. Abernethy, 
who stated to me, that the patient was a lad admitted by Mr. Pott into 
the hospital, with angular distortion in the dorsal region of the spine, 
and complete loss of power in his lower limbs. Issues were made upon 
the spine, and with such effect that the boy speedily regained the power 
of walking. Mr. Pott, delighted at this speedy, and seemingly com- 
plete recovery, detained the boy in the hospital for the object of being 
shown to strangers, as a striking example of the efficacy of the new 
plan of treatment. But in the hospital, the health of the boy declin- 
ed, and he then rapidly sank. Scrofulous disease was found in the 
bodies of the vertebrae, and miliary tubercles had formed in the 
lungs*. 

The cases of disease in the spine, wherein the most expectation of 
benefit from issues may be reasonably entertained, are those of the oc- 
currence of a partial paraplegia in an early stage of the disease, the 
prominent symptoms of which are spasms, numbness, tremulous move- 
Museum of St. Bartholomew's Hospital, Fourth series, No. 14, Plate 21, fig. 3. 

22* 



258 DISEASES OF THE BONES 

ments in the limbs, bespeaking irritation of the spinal cord rather than 
the compression of it. On the other hand, the cases where less expec- 
tation of benefit from issues is to be entertained, are those where the 
advanced stage of spinal disease is accompanied by increasing diminu- 
tion of the motive and sensitive power in the limbs, indicative of either 
a softening of the spinal cord or the actual compression of it. But 
the most unfavourable of all are the cases where sudden and complete 
paraplegia occurred in the advanced stage of spinal disease ; for then 
the cause of the paraplegia is almost sure to be compression of the cord 
by displacement of the bones in the way that has been explained, and 
of which the following is an example. 

Compression of the Spinal Cord by Displacement of the ulcerated 
vertebral bodies. In a youth, aged seventeen, angular distortion of the 
dorsal vertebrae had been gradually increasing for two years, without 
mpairment either of sensation or motion in the limbs ; and then, in the 
course of two days, both lower limbs became completely paraplegic, af- 
ter which he gradually sank. On examining the spine, I found that 
the body of the fourth dorsal vertebra was almost wholly destroyed, 
whilst the bodies of the third and fifth vertebrae were ulcerated only in 
their front parts ; the posterior parts of these vertebral bodies being 
forced backwards into the spinal, had constricted the cord. A para- 
plegia thus produced must of course be irremediable. 

In diseases of the spine, the reparative processes, under the most 
favourable circumstances, are of slow progress. When any of the ver- 
tebral bodies have been destroyed, it is not to be expected that osse- 
ous union of the healthy vertebrae bounding the seat of the disease 
will be completed in less than a year. Accordingly, within a shorter 
period than this, it will not be safe for the patient to resume the erect 
posture. In a boy who had disease in the last dorsal and first lumbar 
vertebrae, accompanied by paraplegia, issues were made upon the spine 
with the effect of restoring the use of the limbs. Only a few months 
had elapsed from the commencement of the treatment ; yet he was 
able to walk ; in descending a ladder he missed a step, but alighted on 
his feet. He said that this jarred him very much. Convulsions of the 
limbs immediately ensued, and fever followed, which in a few days was 
fatal. On examining the spine, I found purulent fluid around the 
theca of the cord. The vertebrae bounding the seat of the disease 
were but weakly united by incomplete bridges of osseous substance, 



OF THE SPINE. 259 

extending over the front surface of their bodies*. It was evident that 
the boy had walked with an insecure condition of the spine, and hence 
the fatal consequences of an accident which otherwise would probably 
have been harmless. 

Much caution is necessary in pronouncing upon the condition of a 
spine which has been once the seat of disease, whatever time has elaps- 
ed since it commenced, and however favourable may be the apparent 
condition of the patient ; for, in some examinations, I have found a 
wide gap in the front of the spine, when, from the ease and firmness 
with which the patient walked, there was the best reason for presuming, 
■hat the consolidation of the vertebrae, above and below the. seat of the 
disease, had taken place. And, in such instances, I have, found, that 
the approximation of the healthy vertebral bodies had been prevent- 
ed by anchylosis of their articular processes ; but that this had 
given sufficient strength to the spine for the maintenance of the 
erect posture, notwithstanding the persistence of the gap in its front 
part, where the vertebral bodies were destroyed. 

PSOAS ABSCESS. 

In its principal features, psoas abscess is so intimately connected 
with diseases hi the vertebrae, that its history is here introduced. 

Under this designation are usually comprised the collections of sero- 
purulent or purulent fluid, or of scrofulous deposit, fluid or consistent, 
formed either in the psoas muscle, or in the cellular tissue adjacent 
to it. 

The frequent seat of psoas abscess is the cellular tissue upon the 
front of the psoas muscle ; it is also found by the side of the muscle, 
and behind it, and occasionally in the centre of the muscle. In the 
latter case, the tumor of the abscess is oblong or spindle-shaped, in 
correspondence with the form of the muscle ; and it is well to note this, 
as there are instances of psoas abscess presenting no other evidence 
of its existence than by the recognition of this oblong or spindle-shaped 
swelling through the relaxed abdominal parietes. 

In a large proportion of cases, psoas abscess is accompanied by 
scrofulous disease of the vertebrae ; but it is, in some instances, accom- 
panied by simply ulcerative disease, commencing either in the verte- 
bral bodies or fibro-cartilages. In some cases, the morbid change in 
the vertebrae accompanying psoas abscess, is nothing more than the 

* Museum of St. Bartholomew's Hospital, Fourth series, No. 15. 



260 DISEASES OF THE BONES 

slight absorption of the surface of the bones, with which the purulent 
or scrofulous deposit had been in contact. And there are instances of 
psoas abscess accompanied by perfect soundness of the vertebrae and 
their fibro-cartilages. I have happened to examine three such cases 
in which no morbid change could be discovered in any of the vertebral 
structures. Although such cases are rare, the knowledge of them is 
important, as it instructs us not to regard a psoas abscess as sure evi- 
dence of disease in the spine. 

A remarkable effect of psoas abscess is, to withdraw from the spinal 
cord whatever irritation had previously been excited in it by the dis- 
ease in the vertebral structures. Accordingly, it has been observed, 
that in diseases of the spine, the co-existence of psoas abscess with the 
impairment of motion and sensation in the limbs is most rare. I can- 
not state that I have known a well-marked instance of it. And to the 
same effect is the observation, that issues are productive of no benefit 
after the formation of psoas abscess ; for the suppuration of the ab- 
scess has already withdrawn all irritation from the spinal cord. 

In a certain number of cases, psoas abscess remains within the ab- 
domen, confined to the neighbourhood of the psoas muscle ; but more 
frequently it extends downwards, in the direction of the tendon of the 
psoas into the thigh : and here it appears on one or other side of the 
femoral vessels, or in front of them. Occasionally, the abscess takes 
its course downwards, behind the femoral vessels. I have examined 
three such cases, and, in two of them, the pulsations of the femoral 
artery had been recognized upon the front of the swelling. Dupuy- 
tren has stated, that he was sent for to open an abscess in the thigh, 
and was surprised to see pulsation on its front part. He supposed it 
must be an aneurism, until he perceived that the throbbing was con- 
fined to a narrow line of the tumor, and thus he became convinced that 
the femoral artery was only lifted up*. These, moreover, are the 
cases where the psoas abscess has been observed to extend to the 
lower part of the thigh ; and it has descended even as low as the ham. 

There have been instances of psoas abscess following the course of 
the tendon of the psoas muscle to the trochanter minor, and then 
passing on the inner-side of the femur to the posterior part of the 
thigh, where the abscess has presented in the space between the tuber 
ischii and trochanter major. Such had been the course of the abscess 
in several instances which I examined. 

* Lesons Orales, t. i. 



OF THE SPINE. 261 

There have also been instances of psoas abscess in which the matter 
has descended from the abdomen into the pelvis, and has then passed 
through the great ischiatic hole backwards to the nates, where it has 
presented near the anus. And, in many of these cases, the lodgment 
of the matter within the pelvis has been followed by destruction of the 
sacro-iliac articulation, and by necrosis of portions of the sacrum, or os 
innominatum, and, in other instances, by ulceration of the coats of the 
bladder, or rectum, through either of which organs, the matter has 
in this way, found an outlet. 

An exception to the ordinary characters of psoas abscess presenting 
in the thigh has arisen in the following way. The pressure of the con- 
fined matter has caused the absorption of the fascia lata to a small ex- 
tent ; consequently, the matter has passed through a small aperture in 
the fascia into the subcutaneous adipose and cellular tissue, and here 
the cyst of the abscess has formed a circumscribed and pendulous 
swelling of an adipose tumor as to have been mistaken for it, in more 
than one instance within my own knowledge ; an operation having been, 
in one case, undertaken for the removal of the supposed adipose tu- 
mor, which proved to be part of the cyst of a psoas abscess. 

Of the same characters as psoas abscess, is the abscess which, in 
many instances of disease in the vertebrae, and their fibro-cartilages, 
presents posteriorly, near the spine, either upon the posterior parts of 
the ribs, or lower down, in the space between the last rib and the ilium. 

It may be of use here to note the chief points of distinction between 
psoas abscess and the iliac abscess, as it is designated from its seat in 
the iliac fossa. 

Hiac abscess is ordinarily formed either in the cellular tissue between 
the peritoneum and the fascia iliaca, or between the fascia and the ilia- 
cus muscle. It consists, in most instances, of a purulent, or sero-puru- 
lent fluid, not of the more consistent scrofulous deposit which so fre- 
quently forms the contents of psoas abscess. 

Iliac abscess is, in many instances, directly referrible to one or other 
of the following occurrences — exposure to cold, strain of the lumbar 
muscles, fall upon the loins ; but it is also not an infrequent consequence 
of simple weakness of the system, however induced. Under these cir- 
cumstances, it often occurs in females, as a consequence of parturition. 
Iliac abscess, moreover, is one of the examples of local suppurative in- 
flammation, the consequence of acute rheumatism. A man, aged 
twenty-one, was admitted into St. Bartholomew's Hospital under the 



262 DISEASES OP THE BONES 

care of Dr. Burrows, suffering from acute rheumatism in several of his 
joints. He had also a large collection of matter in the right iliac fos- 
sa, and extending downwards to the front of the thigh on the inside of 
the femoral vessels. Soon after his admission, he died suddenly from 
inflammation in the membranes of the brain. On examination, the ab- 
scess was found to be situated between the iliacus interims and its fas- 
cia, and it was continued upwards upon the psoas muscle of the spine ; 
but there was no morbid change in any of the structures of the spine. 

Between the iliac and psoas abscess, there is this important differ- 
ence, that the latter, far more frequently than the former, is accompa- 
nied by disease in the vertebrae. And it is for this reason that experi- 
ence shows a larger proportion of perfect recoveries from iliac than 
from psoas abscess. Other distinguishing features of iliac abscess are, 
that it usually presents just above Poupart's ligament, near the anteri- 
or superior spine of the ilium. Occasionally, the absorption of the 
fascia iliaca, in the line of its attachment to Poupart's ligament, per- 
mits the matter of iliac abscess to descend beneath the ligament to the 
front and outer part of the thigh. There are, moreover, cases where 
the matter of the iliac abscess had descended through the inguinal ca- 
nal to the groin. Of this occurrence I have seen several instances, 
but only in male adults, as might be expected from the larger dimen- 
sions of the inguinal canal and its openings in them than in females. 

Between iliac and psoas abscess there is a difference in respect to 
the most usual periods of their occurrence. Psoas abscess is most fre- 
quent in young persons, whilst iliac abscess is rare in children ; its or- 
dinary occurrence is in adults, but before the middle period in life. 

There are other circumstances which may be of some help to the di- 
agnosis between iliac and psoas abscess in the early stage of each, when 
the disease had not passed its first stage of thickening and induration 
of the cellular tissue of the iliac fossa in the one case, and along the 
line of the psoas muscle in the other. Pain in the back and tender- 
ness of the spinous processes of the lumbar vertebrae are the premoni- 
tory symptoms alike of iliac and psoas abscess. But it has appeared 
to me that, during the formation of iliac abscess, the patients usually 
suffer much less inconvenience in walking than during the formation of 
psoas abscess, apparently from the restraint in the action of the psoas 
muscle. Thus, in the early stage of psoas abscess, great difficulty and 
distress are usually experienced in the endeavour to extend the thigh 
fully, and evidently from the rigidity and contraction of the psoas 
muscle. In young persons, moreover, the gait which is attendant on 



OF THE SPINE. 263 

an incipient psoas abscess, bears sufficient resemblance to that of dis- 
ease in the hip-joint to be mistaken for it, which I have known to hap- 
pen in several instances. Detection of the real disease, under such 
circumstances, will rest on the observation of the rigidity of the tendon 
of the psoas, just below Poupart's ligament, and of the tenderness, 
probably with induration, just above Poupart's ligament, and continued 
upwards in the line of the psoas muscle. 

TREATMENT OF PSOAS ABSCESS. 

But few observations on this part of the subject can here with ad- 
vantage be offered. 

It is an important feature of psoas abscess, in its bearing on the con- 
sideration of the treatment, that in a certain number of cases the ab- 
scess, when fully formed, will remain stationary, exciting no more in- 
flammation in the adjacent parts than will be sufficient to wall-in the 
matter, and confine it within its original limits. Thus the abscess may 
continue for an indefinite period, interfering but little with the active 
occupations of life. I have known instances of psoas abscess so con- 
tinuing for many years, with no other evidence of its existence than 
the persistence of the swelling ; with, however, some diminution of it, 
and an increase in its firmness. In the instances where such psoas ab- 
scesses of old formation have, at a distant period, been examined, the 
matter was found converted into a solid substance, having the physical 
and chemical qualities of adipocire*. 

The knowledge of the fact, that even in a small proportion of cases, 
a psoas abscess has been observed to undergo no change prejudicial to 
the part, or to the health of the individual, furnishes a ground for not 
interfering with the abscess by- puncture, or other means to the same 
effect. But there is another, and still better reason for abstaining 
from such interference, because it applies to a larger proportion of 
cases ; it is, that the disappearance of the abscess may take place by 
the absorption of its contents ; and in this way the disease be removed 
by what may be termed a natural process of cure. I know the opin- 
ion has been expressed, and upon good authority, that collections of 
purulent fluid never in this way disappear ; but I am sure of the fact 
that they occasionally do so, by the observation of instances of the 
disappearance of psoas, but more frequently of iliac abscesses ; also of 

* Dupuytren Le9ons Orales, t i. 



264 DISEASES OE THE EONES 

instances of the dispersion of chronic abscesses, elsewhere situated, by 
the application of blisters to the integuments covering them. 

The foregoing considerations lead, I think, irresistibly to the con- 
clusion of not opening either an iliac or psoas abscess until it is just 
about to burst, when, either for the relief of the painful distension of 
the integuments, or to prevent the ulceration of them, the opening may 
be expedient. And then, certainly, it is desirable that the opening 
should be so free as to afford the readiest outlet for the contents of the 
abscess, that the matter may not, by lodging any where, give rise to 
disease in any of the adjacent bones or joints. 

The means calculated to effect the dispersion of an iliac or psoas 
abscess, are such measures of diet, medicine, and general manage- 
ment as will impart strength to the system ; and I can state, that I 
have known cases wherein, after but little expectation had been enter- 
tained of the dispersion of the abscess, yet by the vigorous prosecu- 
tion of these measures the abscess gradually and permanently disap. 
peared. The following cases will be sufficient illustrations of this fact. 

Iliac abscess; its disappearance by absorption of the matter. A 
man, aged twenty-four, of slender frame and hectic aspect, was ad- 
mitted into St. Bartholomew's Hospital with an abscess extending from 
the iliac fossa to the front of the thigh. The extent of the abscess was 
recognized not so much by the swelling as by the fluctuation of its con- 
tents extending over a large space, partly below Poupart's ligament, 
and partly above it, in the direction of the iliac fossa. From Pou- 
part's ligament, the abscess extended three inches down the front of 
the thigh, on the outside of the femoral vessels. The abscess could 
not be ascribed to any local cause. It had been several months in 
progress, and there was no reason for believing that disease existed in 
the spine. The man remained in the hospital about two months, 
during which he was confined to his bed ; and in other respects the 
treatment was directed simply to the support of his general health, 
and through this period the abscess was stationary. The man now left 
the hospital, and proceeded to Margate, where he remained for the 
next seven weeks. He then returned to London, with his health great- 
ly improved ; and on examining him, I found, to my surprise, that the 
abscess had wholly disappeared. There remained only some indura- 
tion, but no tenderness in the seat of it. 

Iliac abscess; its disappearance by absorption of the matter. A 
man, aged twenty-seven, was admitted into St. Bartholomew's Hospital 
with an abscess, the size of a hen's egg, projecting from the left iliac 



OF THE SPINE. 265 

fossa. His occupation was that of a bootmaker, and he attributed the 
formation of the abscess to a strain in his loins in a forcible effort to 
draw the last out of a boot. Having remained some weeks in the hos- 
pital, during which the abscess underwent no change, I advised him to 
go into the country : this he did, and remained there for four months. 
On his return to London, I again saw him, when he stated that noth- 
ing had been done to the abscess, but that with the improvement of his 
health, it had gradually disappeared. Firm pressure against the ab- 
dominal parietes towards the iliac fossa now detected a thickening and 
condensation of the tissues, which I presumed to be the remains of the 
cyst of the abscess. 

There is, it must be admitted, a better grounded hope of the favoura- 
ble result of an iliac than of a psoas abscess, for the reason, that iliac 
abscess is less frequently than psoas abscess the concomitant of disease 
in the spine ; and, besides, that in a large proportion of cases, the iliac- 
abscess is of the character of a local malady, brought into action by 
some local cause of irritation applied to the part in which the abscess 
is seated : it may have been a strain, or some unusual effort of the 
lumbar muscles, or exposure of the loins to cold, which in a healthy 
person has determined the suppurative inflammation in the cellular tis- 
sue of the iliac fossa. Again, psoas abscess, associated with scrofulous 
disease of the vertebrae, frequently co-exists with phthisis. In the ma- 
jority of cases of psoas abscess which I have examined, there was tu- 
bercle in the lungs. 

The following is an example of iliac abscess occurring under circum- 
stances favourable to its successful treatment. 

Iliac abscess presenting at the inguinal ring ; its puncture and cure. 
A man, twenty-five years of age, of robust frame, was admitted into 
St. Bartholomew's Hospital with a large soft swelling in the situation 
of the internal inguinal ring : it was of oval form, its long axis measur- 
ing three inches in the direction of Poupart's ligament ; and in cough- 
ing, a forcible impulse was communicated to it. On the first view of 
the swelling, it was supposed to be a hernia, but on closer examination, 
a fulness and fluctuation were detected in the iliac fossa, clearly indica- 
tive of the nature of the disease. The man stated, that about six 
months previously, he sprained his loins in lifting a heavy weight, which 
was followed by severe pain in his back, enduring for many days, and 
that the swelling in the groin commenced about six weeks ago. As the 
integuments covering the swelling were becoming discoloured, I punc- 

23 



266 DISEASES OF THE BONES 

tured it, and a pint and a half of creamy and flaky fluid flowed from 
the opening. No constitutional disturbance followed the puncture : the 
purulent discharge gradually diminishing, it wholly ceased ; and after a 
few weeks, the man left the hospital perfectly well. 

OP DISEASES IN THE FIRST AND SECOND CERVICAL VERTEBRA. 

A distinct notice of diseases in this portion of the spine is suggest- 
ed by the peculiar circumstances of their history. 

The diseases of ordinary occurrence in the first and second verte- 
brae are ulceration of the ligaments and bones, and softening of the 
bones, with the deposit of tuberculous matter through their cancellous 
texture. The peculiar danger attendant on the progress of these dis- 
eases is, lest any displacement of the bones should ensue, causing com- 
pression of the spinal cord. A fatal result in this way does, however, 
but rarely happen. The ordinary progress of these diseases is as fol- 
lows, — that after the destruction of a certain amount of bone, the dis- 
ease ceases, and the adjacent osseous surfaces become anchylosed, with, 
of course, the loss of the motions of the head upon the spine, the head 
becoming immovably fixed, and often, besides, inclined to the side on 
which the chief destruction of bone has taken place. There are, how- 
ever, instances of ulceration of the first and second cervical vertebrae 
occurring at an advanced age, when it is not to be expected that any 
change of the character of a reparative process will ensue, but rather 
that the ulceration of the bones will continue to the destruction of life, 
which, in cases of this kind, has happened within a few months from 
the commencement of the disease. 

The following case occurred under the observation of the late Dr. 
Hope, of St. George's Hospital, by whom the narrative of it was writ- 
ten. It exhibits an instructive view of the symptoms often accompany- 
ing disease of the first and second vertebrae ; it is of interest, besides, 
as an instance of the displacement of the diseased parts causing the 
sudden extinction of life by compression of the spinal cord. 

" John Henry, an African, aged twenty-one, a plumber, was admit- 
ted into the Marylebone Infirmary, affected with complete fixity of the 
head on the neck, preceded by intense and constant pain referred to 
the origins of the sterno-cleido-mastoid muscles, and of the posterior 
muscles of the neck, deep under the occipital bone. He carried the 
head immovably erect, and whilst performing any motion of the neck, 
he sustained the head by applying his hands to each side of the face. 



OF THE SPINE. 267 

He had constant headache, accompanied by a sense of pulsation in the 
temples and forehead, with a throbbing and excessive pain in the jaws 
and teeth, similar to that of toothache. These symptoms were aggra- 
vated by stooping, by hot or stimulating food, or by any acceleration of 
the circulation, and they were alleviated at pleasure by compression of 
the carotid arteries. The pulse was ninety,. full and strong ; the tongue 
furred and white ; bowels costive. The first symptoms of the disease 
were the pain and rigidity in the neck, which commenced ten months 
previously, and were ascribed to exposure to cold during perspiration. 
Leeches, blisters, sinapisms, ung. tart, antim., and stimulating liniments 
had been employed, but only with temporary relief. Sixteen hours be- 
fore his death he became affected with universal paralysis. Whilst in 
the act of being raised from the recumbent position, his head suddenly 
fell forwards, and he instantly expired. 

Caclav. Sectio. — Serous effusion under the arachnoid membrane of 
the brain. One ounce of serum in the lateral ventricles. Base of the 
cerebellum in a state of incipient ramollissement. The ligaments of 
the processus dentatus were completely destroyed by ulceration. The 
whole superior surface of the atlas, with the corresponding parts of the 
occipital bone, were denuded of periosteum, and presented several deep 
excavations. The transverse ligament of the atlas was so far absorbed 
as to have allowed the odontoid process to escape from beneath it, and 
compress the spinal cord." 

MALIGNANT DISEASES OF THE SPINE. 

In the section which treats of carcinoma in bone, an instance of hard 
carcinoma is described, which occurred as a primary disease in the 
mammary gland, and, secondarily, in various bones, including those of 
the spine. The following is an instance of another form of carcinoma- 
tous deposit, probably occurring as a primary disease in the spine, and 
in the ribs. 

A female, between sixty and seventy years old, was admitted into 
St. Bartholomew's Hospital, under the care of Dr. Burrows, with para- 
plegia, which had commenced three months previously. There was 
complete loss of motion in the lower extremities, and in the lower half 
of the trunk ; the faeces passed involuntarily, but the urine was retain- 
ed. She complained of numbness in the motionless parts, but could 
feel distinctly when they were touched. She had no pain in the back, 
nor was any part of the spine painful on pressure. She gradually sank, 



268 DISEASES OF THE BONES 

and died five days after her admission with sloughing over the sacrum. 
On examination, a large carcinomatous tumor was found in the liver ; 
the bladder was thickened and distended with strongly ammoniacal 
urine ; its mucous membrane was ulcerated and covered with flakes of 
fibrin. The spinal cord, opposite to, and below the seventh dorsal ver- 
tebra, was so soft as to resemble thick cream, and it was of a yellow 
colour. Around several of the ribs and involving their tissue, there 
were carcinomatous tumors. A tumour of the same kind had formed 
beneath the pleura, by the side of the seventh dorsal vertebra, and the 
whole body of this vertebra was so softened that it could be broken up 
with the finger. The substance of the tumor was not distinctly con- 
tinued into the diseased vertebra ; but there was a mass of similar mor- 
bid substance between this vertebra and the theca of the cord, to which 
it closely adhered, opposite to the point where the softening of the cord 
commenced. The posterior surfaces of the dorsal vertebrae, from the 
seventh to the last, were slightly ulcerated. All the carcinomatous 
masses were white and firm, with an appearance of fibrous bands radia- 
ting through them, and interspersed with points of a yellow-ochre and 
soft substance. 

In the foregoing case, the carcinomatous deposit in the spine and 
ribs was probably a primary disease. But, in most other instances, the 
malignant disease in the spine has been preceded by carcinoma in the 
breast ; so at least it was inferred, from the fact, that the symptoms of 
the spinal disease first occurred long after the appearance of carcino- 
matous disease in the mammary gland*. The vertebrae, when attacked 
by malignant disease, are found softened and extremely vascular, with 
their cells filled by hard carcinomatous, or encephaloid, or melanotic 
deposit. In some of these cases, the spinal cord is simply softened at 
the seat of the disease in the vertebrae ; in others, it is compressed by 
part of the morbid growth arising from the bones, or from the mem- 
branes of the cord, and projecting into the spinal canal. There is also, 
in general, much fluid effused into the theca of the cord. 

The symptoms of malignant disease in the spine are of the same 
general character as those of other destructive diseases in the vertebrae. 
Malignant disease of the spine does however, in most instances, exhibit 

* Cases of Cancerous or Malignant Disease of the Spinal Column, by Csesar Haw- 
kins, Surgeon to St. George's Hospital. Medico- Chirurgical Transactions, Vol. xxiv. 



OP THE SPINE. 269 

one prominent feature which would at once distinguish it with certainty 
from other spinal diseases, if it were of constant occurrence ; this is 
£he very severe pain in the vertebrae, and, besides, the severely painful 
affections of the parts supplied by the nerves issuing from the diseased 
portion of the spine. Thus, almost invariably, in malignant disease of 
the vertebras, the pain in the back has been constant and agonizing. 
But unfortunately, in some few cases, it has been decidedly otherwise, 
and the impaired sensation and motive power in the limbs were not pre- 
ceded, or accompanied, by any pain in the diseased vertebrae ; the 
symptoms were exactly such as attend the ordinary forms of spinal 
disease. So far it may be confidently stated, that the existence of con- 
stant and severe pain in the spine, in conjunction with the symptoms of 
disorganization in the spinal cord, are strong grounds for apprehending 
that the vertebrae are attacked by malignant disease, but that the ab- 
sence of severe pain in the spine is not sure evidence of the disease in 
it being otherwise than of a malignant nature. 

Malignant diseases of the spine in general proceed rapidly to a fatal 
termination, as, indeed, might be expected, from the severity of their 
symptoms. Exhaustion of the vital powers by pain has, in most cases, 
brought the disease to its fatal result in the course of a few months 
from its commencement. 



23* 



CH A PTER III. 



DISEASES OF PERIOSTEUM. 

INFLAMMATION OF PERIOSTEUM. 

Syphilis, rheumatism, and scrofula are well-recognized causes of in- 
flammation of periosteum ; it also occurs, secondarily, from inflamma- 
tion in the medullary membrane, or walls of the bone. In systems de- 
bilitated by mercury, and thus rendered particularly susceptible of the 
influences of cold and moisture, inflammation of periosteum upon one, 
and often on several bones, is of common occurrence ; these belong to 
the class of rheumatic cases, and it is probably because the surfaces of 
bones superficially situated are most exposed to external influences, 
that these are the usual seat of periostitis. By the same consideration 
it may be explained why periostitis upon the posterior surface of the 
tibia is rare ; and fortunately it is so, for the serous or purulent fluid, 
here effused beneath the periosteum, would be scarcely within reach of 
relief by surgical interference. 

Among the examples of syphilitic periostitis are instances of its oc- 
currence from the action of the gonorrheal virus alone, and indepen- 
dently of rheumatism. The following is a well-marked case of this 
kind. A gentleman had, in the course of ten years, three attacks of 
gonorrhoea, all severe and lasting a long time. During the last three 
years, he had suffered from periostitis, first upon the sternum, then up- 
on the cranium. When I saw him, there were several small, firm swel- 
lings, from thickening and induration of the pericranium. He stated, 
that he had had a multitude of such swellings upon every part of the 
head, which he had subdued by leeches. He had taken no mercury, 
and had never suffered from rheumatism. 

Acute inflammation of periosteum occasions increase of its vasculari- 
ty— thickening and softening of its tissue-— loosening of its connexion 



DISEASES OF PERIOSTEUM. 271 

with the bone — serous or purulent effusion between it and the bone. 
Less acute or chronic inflammation of periosteum occasions thickening 
and induration of its tissue — increased firmness of its adhesion to the 
bone — osseous deposit in its indurated tissue. The following appears 
to be the process of thickening and induration of periosteum. First, 
its texture softens, and is seemingly unravelled ; then, gelatinous sub- 
stance is deposited into the meshes of the softened tissue, and harden- 
ing, gives it the density of fibro-cartilage. 

Inflammation of periosteum occasions in the subjacent bone expan- 
sion, hardening and thickening of its substance, ulceration, or necrosis 
of its surface. 

Distinct forms of disease have their particular effects on periosteum ; 
thus, from rheumatism, diffuse inflammation of it ensues, followed by 
thickening of its tissue, or ulceration of it, and occasionally by ulcera- 
tion, or necrosis of the surface of the bone, by expansion or thickening 
of its tissue. 

Syphilis attacks distinct portions of periosteum, and gives rise to 
serous or purulent effusion beneath it, to thickening and ossification of 
its tissue, and to the expansion or thickening of the subjacent bone. It 
is probable the osseous node is always preceded by thickening and in- 
duration of the periosteum. The degree of hardness of a node does 
not, with certainty, indicate its composition. I have examined nodes 
which, from their hardness, were supposed to be osseous, and have 
found them to consist of indurated periosteum. It is probable, that the 
osseous substance in a node is always a permanent deposit ; therefore, 
that when, by the application of blisters or other remedies, nodes have 
disappeared, they consisted of thickened periosteum. The syphilitic 
node is circumscribed, and of a roundish figure ; and by these charac- 
ters, it is distinguished from other enlargements of periosteum, or bone. 
But rheumatism and syphilis are so frequently combined, that the dis- 
tinction of their specific effects on periosteum and bone is often lost. 

Here it may be observed, that the osseous node does not occur upon 
the cranium ; so far does the pericranium differ from periosteum in its 
actions under the influence of disease, that under no circumstance does 
its tissue become ossified. When, from syphilis, isolated portions of 
the pericranium inflame, circumscribed swellings arise, which are hard 
and painless, when consisting only of the thickened pericranium — but 



272 DISEASES OF PERIOSTEUM. 

soft and tender, when produced by serous or purulent effusion, either 
beneath the pericranium or into the cellular tissue covering it. In the 
latter case they have received the expressive designation of soft nodes. 

Scrofula in periosteum produces thickening and induration of its tis- 
sue ; and, in some cases, serous or purulent effusion into its thickened 
tissue, or between it and the bone. 

Scrofulous thicken' ng of periosteum gives rise to a hard and painless 
swelling, which, in a cylindrical bone, usually occupies its entire cir- 
cumference. This is the disease of frequent occurrence upon the bones 
•of the fingers in children, enlarging the finger, and giving to it the ap- 
p earances of disease in the bone. The same changes occur from scro- 
fula, in the periosteum of flat bones, especially of those of the cranium 
and face ; also, upon the long bones, especially the humerus, radius, 
ulna, and tibia. And here the thickening and induration of the perios- 
teum occasions a firm, solid swelling over the entire circumference of 
the bone, which it is often difficult to distinguish from enlargement of 
the bone itself. 

Scrofulous thickening of periosteum is a curable disease — thus, in 
the instances of its occurrence upon the bones of the fingers, the en- 
largement of the finger which it occasions, although of long endurance, 
yet, with improvement in the general health, often wholly subsides, 
leaving the finger in a perfectly healthy condition. 

The changes from scrofula in periosteum are characterized by the 
small amount of accompanying irritation. Even when, from scrofulous 
inflammation of periosteum, serous or purulent effusion has taken place 
beneath it, yet, because of the softening of its tissue, none of the acute 
pain and severe constitutional derangement ensue which accompany 
such effusions occurring under other circumstances. 

Suppuration in the tissue of periosteum, thickened by scrofulous in- 
flammation, or beneath the thickened membrane, is often followed by 
ulceration of the subjacent bone, and occasionally by exfoliations from 
its surface. But the disease is still curable, and without deformity ; 
and, in this respect, scrofulous inflammation of periosteum, through all 
its consequences, is strikingly contrasted with the effects of scrofulous 
disease in bone, which has advanced to its tuberculous stage ; for here, 
deformity must ensue, as the consequence of the destruction of the dis- 
eased bone not being followed by any reproduction of it. 

Scrofulous inflammation often attacks the periosteum upon several 
bones simultaneously, or in quick succession, occasioning thickening of 



DISEASES OP PERIOSTEUM. 273 

the membrane upon some bones, serous or purulent effusion beneath it 
upon others, and then being followed by superficial ulceration of the 
bone, or by small exfoliations from it. Moreover, when scrofulous in- 
flammation has attacked the periosteum of one bone, if disease should 
arise in other bones simultaneously, or in succession, it is almost sure to 
be of the same character ; that is, it will be confined to the perioste- 
um, and, therefore, be curable without destruction of the bone and the 
deformity consequent on it. 

Inflammation of periosteum near a joint is apt to extend to the syno- 
vial membrane ; thus instances occur of inflammation in the knee-joint, 
apparently by an extension of rheumatic inflammation from the perios- 
teum of the tibia ; and there are instances of destructive inflammation 
of both the knee and the ankle-joint, the consequence of scrofulous in- 
flammation of the periosteum upon the adjacent parts of the tibia. 
But, amidst the complications of these diseases, there are, also, in- 
stances in which inflammation extends from the synovial membrane of a 
joint to the periosteum of the adjacent bones. A girl in St. Bartholo- 
mew's Hospital received an injury to the elbow-joint, which occasioned 
acute inflammation of its synovial membrane ; by local depletion and 
the other parts of a soothing treatment, the inflammation of the joint 
was completely subdued. She now became distressed by acute and 
deep-seated tenderness in the adjacent parts of the arm and fore-arm, 
evidently the consequence of inflammation in the periosteum upon the 
humerus, radius, and ulna, which readily yielded to the administration 
of iodide of potassium. 

There is an example of periostitis deserving particular notice, on ac- 
count of the severity of its effects, — this is upon the pelvis, and mostly 
upon its posterior part, and when it occurs near to the hip-joint, its 
symptoms so much resemble those of disease in the joint itself, that 
they are apt to be mistaken for them. The severest and most distinctly 
marked cases of this description which I have seen, occurred in females, 
and apparently as a secondary affection succeeding to parturition. The 
following is the history of one of these cases. 

Periostitis upon the Pelvis. The patient stated that, on the eighth 
day after her labour, she was attacked with acute and deep-seated pain 
behind the left hip-joint, and that this pain continued without remission 
through the next five weeks, when she became a patient in St. Barthol- 
omew's Hospital. I found the parts between the left hip-joint and the 



274 DISEASES OF PERIOSTEUM. 

sacrum tense and acutely tender ; but there was no increased heat, in- 
flammatory swelling, or redness ; the tenderness and tension extended 
around the crista of the ilium to its inner surface, and the pain was 
greatly aggravated by the slightest movement of the hip-joint. For 
several weeks, I expected the patient would become exhausted by the 
severity of the pain. At length a fulness was perceived, just above 
Poupart's ligament, near the spine of the ilium ; and an opening here 
formed, from which matter was discharged with some relief. Soon af- 
terwards, I discovered a fulness and fluctuation at the back of the pel- 
vis, a little below the crista of the ilium ; and here I made an incision, 
discharging about six ounces of matter. With a probe passed into the 
opening, I discovered that the matter had formed close upon the dor- 
sum of the ilium, which was deprived of its periosteum. Immense re- 
lief was obtained by this discharge of matter, and, in a few days after- 
wards, it became evident that the painful movements of the hip-joint 
were owing to its contiguity to the inflamed structures, and that the 
joint itself was sound. The seat of inflammation had here been the 
periosteum of the ilium, and probably on both its surfaces. 

In another instance of periostitis consequent on parturition, the dis- 
ease, in a milder form, was confined to the dorsum of the ilium, where, 
however, it was characterized by the same deep and acute tenderness 
continuing until relief was obtained by the discharge of matter. In 
both cases, the fulness, and fluctuation of matter, upon the ilium were 
discovered a little below the crista, and just in front of the anterior 
border of the glutaeus maximus muscle, the incision being here made 
through the glutaeus medius to the bone. 

I have met with other instances of periostitis upon the posterior part 
of the pelvis, referrible only to rheumatism, in which the deep-seated 
fluctuation and pain indicated the existence of effusion, probably of se- 
rous fluid, beneath the periosteum ; but, during the administration of 
iodide of potassium, with some help, perhaps, from a plaster of mercu- 
ry and ammoniacum, the disease gradually subsided, without any dis- 
charge of the effused fluid. 

It may be well here to notice another class of cases of rheumatic in- 
flammation affecting the periosteum covering the trochanter major of 
the femur, which, from the situation of the disease, is apt to be mista- 
ken for inflammation in the hip-joint. Tenderness and thickening of 
the tissues immediately around the trochanter, giving to it increased 
breadth and prominence, are the immediate consequences of the in- 



DISEASES OP PERIOSTEUM. 275 

flammation of its periosteum. "When not arrested at its commence- 
ment, the periostitis so situated is not infrequently followed by necrosis 
of small portions of the trochanter ; and, in such cases, the exfoliation 
of the dead bone is, in general, an extremely slow process. I have 
known cases where the patients were, from this cause, disabled for 
many months, with a fistulous passage in the outer part of the thigh, 
constantly discharging, and leading to the dead bone. 

TREATMENT OP INFLAMMATION OF PERIOSTEUM. 

The most certain means of arresting acute inflammation of perioste- 
um are, local depletion, soothing applications, and the constitutional ac- 
tion of mercury. Accordingly, the free exhibition of calomel and opi- 
um, combined with the repeated applications of leeches, poultices, and 
fomentations are the measures to be actively pursued for the object of 
subduing acute inflammation of periosteum before it reaches the stage 
of serous or purulent effusion. 

For the less acute inflammation of periosteum, iodide of potassium 
is to be regarded as the specific remedy ; for it very rarely fails to 
stop the progress of the disease, and, in much the largest proportion of 
cases, completely cures it. This statement of the remedial agency of 
iodide of potassium is to be taken in its most comprehensive sense. 
Whether it be the inflammation of periosteum adjacent to an exfoliating 
bone, or investing an enlarged bone, or that which is the consequence 
of scrofula, syphilis,, or rheumatism, there has not appeared to me to 
be any difference in respect to the influence of this remedy upon the 
disease. And, with respect to the suitable doses of it, I have but to 
repeat the statement already made, that my impression is in favour of 
administering it in doses of two or three grains, three times a day, in 
either decoction of sarsaparilla, or a bitter vegetable infusion, or cam- 
phor mixture. I subjoin the following case, as it was the first record 
which I made of the remarkable influence of iodide of potassium in 
subduing inflammation of periosteum, the consequence of syhilis. 

Syphilitic Periostitis upon several bones — cure by Iodide of Potas- 
sium. A man, aged thirty, was admitted into St. Bartholomew's Hos- 
pital in September, 1832, on account of a sloughing sore on the penis, 
for the cure of which mercury was administered to the extent of pro- 
ducing full salivation ; and he left the hospital with no visible remains 
of disease. In the period between October, 1832, and August, 1835, 
he had several attacks of sore throat, accompanied by eruptions, for 



276 DISEASES OF PERIOSTEUM. 

which, he repeatedly took mercury, and on each occasion of doing so, 
the symptoms disappeared. During the eight months preceding Au- 
gust, 1835, he had suffered severe pain in his shins, for which he had 
not used mercury. On his re-admission into the hospital, there were 
circumscribed inflammatory swellings upon the upper part of each tibia, 
and upon one ulna. These swellings had been so severely painful as 
almost to deprive him of sleep. In the swelling upon the tibia, fluctu- 
ation was evident, from fluid beneath the periosteum. Upon the other 
tibia, and upon the ulna, the swellings appeared to consist of thickened 
and indurated periosteum. No other application was made to the 
swellings than a linseed-meal poultice. Five grains of iodide of potas- 
sium were administered three times a day. On the second night after 
its commencement, the pain had so far ceased that the patient slept 
well. The same dose of iodide of potassium was continued for a fort- 
night, when the tenderness of the diseased parts had wholly subsided, 
and he could bear the part of each bone that had been the seat of dis- 
ease, to be sharply struck without uneasiness. The swellings upon both 
tibiae and upon the ulna had considerably diminished, and the fluid ef- 
fused upon one tibia had disappeared. The man left the hospital whol- 
ly free from complaint. 

In the foregoing case, the iodide of potassium was effectively ad- 
ministered,' in doses of five grains, three times a day ; but, from subse- 
quent experience, it has appeared, that the same amount of benefit 
from it is obtained by the smaller doses of two or three grains. 

Upon the subsidence of acute inflammation in periosteum, the mer- 
curial treatment is often advantageously changed for the administra- 
tion of iodide of potassium. This is well shown in the following case, 
which, besides, is an example of a not infrequent complication of dis- 
eases, namely, periostitis of the femur, with inflammation of the hip. 
joint. 

Periostitis of the Femur with Inflammation of the Hip-joint, the ef- 
fects of rheumatism. A man, aged twenty-five, whose occupation was 
such as almost constantly to expose him to cold and moisture, was ad- 
mitted into St. Bartholomew's Hospital, after a confinement to his bed 
for nine weeks. On his admission, the local symptoms clearly denoted 
the existence of acute inflammation in the hip-joint, with inflammation 
of the periosteum of the shaft of the femur ; his general condition was 
such as might be expected from nine weeks of constant and severe suf- 
fering ; his pulse was frequent and sharp ; tongue dry and furred ; 



DISEASES OF PERIOSTEUM. 277 

countenance sunk, -with general emaciation. In the view of getting 
his constitution speedily under the influence of mercury, I directed 
that mercurial ointment, thickly spread upon lint, should be constantly 
applied around the hip-joint, and around the thigh ; also that he should 
take two grains of calomel with a quarter of a grain of opium, and 
three grains of antimonial powder every three hours. Just in propor- 
tion as the mercurial affection of the system was manifested, so did the 
pain in the hip-joint, and the deep-seated pain around the femur, sub- 
side, with corresponding improvement in the general health. "When 
the gums had become fully affected, I thought that iodide of potassium 
with sarsaparilla, in combination with a generous diet, might be advan- 
tageously administered for the removal of the remaining tenderness in 
the parts that had been so long inflamed, and for the restoration of the 
general health. Under this treatment, amendment in every respect 
was progressive, until every trace of disease had disappeared. The 
man left the hospital with the perfect use of his hip-joint. 

The chief signs of the existence of serous or purulent effusion be- 
neath inflamed periosteum are the sense of tension, with acute and 
persisting pain in the part, accompanied or not by an obscure sense of 
fluctuation. In certain cases, absorption of the effused fluid has ensu- 
ed upon the subsidence of the inflammation in the periosteum ; in 
these, probably, the fluid was of a serous character. However this 
may be, I have known so many instances of acute periostitis upon vari. 
ous bones, followed by the disappearance of all pain, swelling, and 
sense of fluctuation in the part, as to permit no doubt of the occasional 
absorption of fluid effused beneath the inflamed periosteum. The rem- 
edies conducing to this desirable result were iodide of potassium, with 
the plaster of ammoniacum and mercury applied to the affected part. 

But the division of inflamed periosteum is occasionally required, by 
the continued severity of the pain, attributable only to the confinement 
of fluid, serous or purulent, beneath the tense and resisting membrane. 
By the escape of the smallest quantity of fluid from beneath the peri- 
osteum, the relief from pain is immediate and complete. Even in 
cases where the signs of the confinement of fluid beneath the perioste- 
um are not clear and strongly marked, yet if, in spite of the reme- 
dies that have been employed, the pain continues to be severe, the di- 
vision of the membrane may be expedient, on the ground that, by re- 
moving the tension of the inflamed membrane, it will relieve the pain. 
An argument in favour of the early division of inflamed periosteum is, 

24 



278 DISEASES OF PERIOSTEUM. 

that it will prevent disease in the bone, since, in proportion to the du- 
ration and severity of the inflammation in' the periosteum, will be the 
risk of ulceration, or necrosis of the surface of the bone. After the 
division of the periosteum, the closure and speedy healing of the wound 
has been followed by the return of acute pain, indicating a recurrence 
of the inflammatory tension of the membrane. Under such circum- 
stances, a second and even third division of it has been performed. To 
avoid this evil, the immediate adhesion of the sides of the wound should 
be prevented by placing a layer of lint between them, taking care it 
extends to the bone. The subcutaneous incision of inflamed perioste- 
um has been ingeniously suggested, but there are objections to it appa- 
rently of weight ; it would not afford complete relief to the tension of 
the inflamed structures, and it would not remove the congestion of their 
vessels ; indeed, the profuse haemorrhage ensuing from the freely-di- 
vided parts is probably of much service. 

Scrofulous inflammation of periosteum, or rather the state of con- 
stitution which gives rise to it, constitutes one of the forms of disease 
in which cod-liver oil is given with the best effect. In such cases, 
therefore, it is a valuable adjunct to the iodide of potassium, which 
will remove any irritation there may be in the thickened or otherwise 
diseased periosteum, whilst the cod-liver oil, by giving activity to nu- 
trition, and thereby improving the general health, will be the means of 
altering the state of constitution to which scrofulous disease of peri- 
osteum is owing. 

ILLUSTRATIONS OF VARIETIES OF PERIOSTITIS. 

Inflammation of the Pericranium — Treatment by Incision. A mid- 
dle-aged man, of full habit, was admitted into St. Bartholomew's Hos- 
pital, suffering constant and severe pain in his right ear, and over the 
whole of this side of the head, accompanied by much inflammatory 
fever. Puriform discharge issued from the ear, but without relief to 
the pain, which continued most severe, and was attended with ery- 
sipelatous redness and tension of the skin over the whole of this side 
of the head and face. All the local and constitutional antiphlogistic 
remedies perseveringly used afforded only temporary relief, each de- 
pletion by cupping or leeches procuring the alleviation of pain for only 
a few hours. Thus the case had proceeded nearly a month, when I 
made an incision through the coverings of the cranium to the bone, 
from the base of the mastoid process directly upwards, nearly three 



DISEASES OE PERIOSTEUM. 279 

inches, taking care to divide the pericranium to the full extent of the 
outward incision. Not a drop of matter could be detected escaping 
through the wound. The relief from pain, however, was immediate 
and complete, and it could only be ascribed to the removal of the ten- 
sion of the inflamed pericranium. The wound healed soundly, and 
there was no return of the disease. 

There have been instances in which a blow on the head was followed 
by inflammatory changes in the injured part with severe nervous dis- 
order, which endured for several years, and was then completely re- 
lieved by division of the injured portion of the pericranium. The fol- 
lowing belong to this class of cases. 

A woman received a blow on the head, behind the left ear, from the 
immediate effects of which she recovered. But "pain in the injured 
part afterwards arose, and continued for four years : she then had. 
convulsions with paralytic affections. At the place of the injury, a 
small portion of the integument became red, and gentle pressure on 
this part was followed by a convulsion. By a free incision to the bone,, 
and allowing the wound to suppurate, all these complaints were re- 
moved*. 

A boy, aged eight years, received a severe blow on the crown of 
his head. A painful feeling continued in the scalp at the injured part, 
and, for ten years, he was subject to intense headaches. At the age 
of twenty-four, a small swelling arose in the original seat of the injury, 
with redness of the skin ; and pressure on this part occasioned intense 
pain. By a free division of the coverings of the cranium, immediate 
and complete relief was obtained!. 

There are instances of acute periostitis occurring extensively over 
two, or even more, of the long bones simultaneously, or in quick suc- 
cession ; and when it occurs upon two contiguous bones, inflammation 
is almost sure to ensue in the intervening joint. The following is the 
history of such a case. 

Inflammation of the Periosteum of the Tibia and Femur, and of 
the Knee-joint. A girl, fourteen years of age, was admitted into St. 
Bartholomew's Hospital, with deep and extensive suppuration in the 
leg. She stated, that she had received a severe blow on the leg, a 
fortnight before the inflammation in it commenced. Openings had been 

* (Euvres posthumcs de Pouteau, tome ii. Memoire sur le danger des coups a la 
tete. 
tlbid. 



280 DISEASES OF PERIOSTEUM. 

made along the spine of the tibia, for the evacuation of the matter — ■ 
and through these, the whole front surface of the bone was discovered 
to be denuded of periosteum — hence it was supposed that the bone had 
perished. On obtaining, however, a fuller view of the bone, I ob- 
served its surface to possess the pinkish tint of living bone, and, ac- 
cordingly, I concluded the disease had commenced in inflammation of 
the periosteum, followed by suppuration beneath it ; and this proved 
to be the correct view of the disease. As the activity of the inflam- 
matory processes in the leg subsided, severe pain arose in the deep 
structures around the lower third of the thigh ; and, at the same time, 
acute inflammation attacked the synovial membrane of the knee-joint. 
Suppuration ensued beneath the periosteum of the femur ; through an 
incision made in the outer side of the thigh, about eight ounces of 
matter were discharged ; and, at the bottom of the abscess, the bone 
was found to be denuded of its periosteum. From this period there 
was a gradual subsidence of disease in all the three situations it had 
occupied — the leg, thigh, and knee-joint ; and ultimately the patient 
left the hospital with a sound state of the limb*. 

In another variety of disease, inflammation occurs, without appa- 
rent cause, in limited portions of the periosteum, upon several bones at 
different, and often very distant, periods. The following is a case of 
this kind. 

Inflammation in portions of the Periosteum of many hones at dis- 
tant periods. A man, aged twenty-four, was admitted into St. Bar- 
tholomew's Hospital, under the care of Mr. Abernethy, with disease in 
his left leg, which had commenced ten years previously in inflammation 
of the periosteum of the tibia, followed by ulceration of the bone, and 
exfoliations from its surface, after which, the wound had healed, and re- 
mained so for a year ; then, in the same part, fresh ulcerations of the 
bone and exfoliations from it had ensued ; and many times through the 
following years, the same morbid processes had been repeated. Three 
years after the commencement of disease in the left leg, inflammation 
arose in the periosteum of the right tibia, and subsequently of the left 
ulna, followed, in each instance, by exfoliations from the surface of the 
bone. At length, all the parts had become sound excepting the leg 

* Cases similar to the above are recorded by Dr. M'Dowell, as instances of acute in- 
flammation of synovial membrane, combined with inflammation of periosteum, " attack- 
ing different articulations with great rapidity, and causing death in several instances." 
Dublin Journal of Mecical Science, Vols, iii., iv. 



DISEASES OF PERIOSTEUM. 281 

first diseased ; and as this had so long been a source of suffering, Mr. 
Abernethy yielded to the solicitations of the man for its removal. 

On examining the limb", I found the periosteum over nearly the 
whole of the tibia thickened, but it was soft and loosely adherent to 
the bone ; the surface of the bone was rough and irregularly excavat- 
ed, and its medullary texture, in great part, obliterated by osseous de- 
posit. Shortly after the healing of the stump, fresh attacks of in- 
flammation occurred in the periosteum of the right tibia, also in that 
of the ulna, followed by small exfoliations from each bone ; and, on 
the occasion of my last seeing this man, many months after the re- 
moval of his lirab, he was still suffering attacks of inflammation of the 
periosteum upon one or other bone. 

MALIGNANT DISEASE OF PERIOSTEUM. 

I have now to describe a malignant disease of periosteum, the con- 
sequence of long-continued or repeated attacks of inflammation, altering 
its structure and giving rise to the growth of a fungous excrescence 
from it. I have seen this disease only in the front of the leg, probably 
because this is most exposed to injury ; and here, from the thinness of 
the soft coverings, inflammation, more readily than elsewhere, extends 
to the periosteum and bone. Accordingly, this disease is usually 
traced to local injury, followed by repeated inflammatory attacks in the 
skin and subjacent structures, occasioning ulceration of them, includ- 
ing the periosteum, and, in some instances, the bone, with exfoliations 
from its surface. At length, a fungous excrescence arises from the 
diseased parts, which, in some instances is soft and flocculent on its 
surface, with a firm, greyish, gelatinous base, whilst, in others, it con- 
sists of a firm, gelatinous substance throughout. Usually the fungus 
is very sensitive, and, when injured, bleeds very freely. 

The grounds upon which I have considered this to be a disease of 
periosteum are, that, in some instances, the fungous excrescence ap- 
peared to have arisen directly from the periosteum, altered in structure 
by inflammation, that is, thickened and softened, and but loosely ad- 
herent to the bone ; further, that these alterations in the periosteum, 
have been observed to extend beyond the limits of the fungus, and, 
indeed, far beyond the existence of any change in the skin indicating 
unsoundness of the subjacent parts. Thus, in one case, where the 
fungus was confined to the lower third of the front of the leg, the 
periosteum was found preternaturally vascular, thick, soft, and pulpy, 

24* 



282 DISEASES OF PERIOSTEUM. 

over the whole of the tibia and upon the fibula also. It seemed, there- 
fore from these observations, that a diseased state of the periosteum 
had preceded the growth of the fungous excrescence from it. 

In some of the instances of this disease, the softness and flocculence 
of the surface of the fungus have suggested its resemblance to certain 
excrescences arising in the cutaneous tissue, and, accordingly, it has 
b een supposed, that this may be a form of carcinoma originating in 
the skin, and thence spreading through the subjacent structures. A 
circumstance, apparently, according with this view of the nature of 
the disease, was noticed by Mr. Paget, in the examination of a recent 
specimen of it, that there were scales like epithelial scales in it, similar 
to those observed in that form of carcinoma of the skin which consists 
in degeneration of its tissue. 

I have regarded this as a malignant disease, for the following reasons. 
In instances where the fungous excrescence was removed, granulations, 
apparently healthy, have arisen from the exposed surface of the bone, 
but they have gradually assumed the characters of the fungus ; further, 
the spread of the fungus is accompanied by destruction of all the ad- 
jacent structures ; thus, in one case, it penetrated the front wall of the 
tibia, and then spread largely through the interior of the bone ; and 
in another case, it extended completely through the shaft of the tibia. 
The absorbent glands of the thigh and groin, however, have not in 
these cases been affected ; nor has the disease, in any instance which I 
have met with, been accompanied or followed by similar growths else- 
where. Therefore, although for the reasons which have been stated, 
this disease is to be considered malignant, its action is local, so far at 
least, that it does not extend beyond the region of the body in which 
It originates. 

On the practical view to be entertained of this disease, little com- 
ment is necessary. Experience has proved it to be unsafe to trust to 
the excision of the morbid growth, for in instances where this was done, 
and apparently in the most satisfactory manner, the parts exposed by 
the operation appearing perfectly sound, yet the disease was repro- 
duced. The removal of the limb in which the disease is situated is 
the appropriate treatment of it. 

The following are illustrative examples of this disease : — 

I. — A man, aged fifty, stated, that twenty years previously, he 
bruised his leg, the skin at the injured part, inflamed and ulcerated, 
and then became apparently sound. Ulceration had many times re- 
curred "in the same part of the leg. On some occasions it had con- 



DISEASES OF PERIOSTEUM. 283 

tinned sound for several months, and once for about two years. At 
length there arose from the diseased parts, a soft fungous excrescence, 
about three inches in circumference at its base. Various measures for 
repressing the growth of the fungus having been ineffectually tried, the 
limb was amputated. I found the base of the fungus extending to the 
periosteum of the tibia. The periosteum- was but loosely adherent to 
the bone, and its inner surface was soft and flocculent. This condition 
of the periosteum, with increase of its thickness, extended over the 
tibia some way beyond the limits of the fungus. The surface of the 
bone beneath the diseased periosteum was rough, in some parts from 
absorption, in others from osseous deposits.* 

II. — 'A woman, aged thirty-five, stated, that at the age of ten years, 
she received a severe blow on her leg ; this was followed by a succ es- 
sion of abscesses in the injured part, and by the discharge of numer- 
ous small pieces of bone. At one period, the parts remained apparent- 
ly sound for several years ; then there occurred, and without obvious 
cause, fresh attacks of inflammation and more exfoliations. A large 
and very soft fungous excrescence now arose from the front of the leg, 
and it was deemed right to amputate the limb. I injected its vessels ; 
the fungus was found to be very vascular, and through the whole of its 
base, closely identified with the periosteum, which was soft and floccu- 
lent, and very readily separable from the bone. Upon the whole of 
the tibia, as well as upon the fibula, the periosteum was preternaturally 
vascular, soft, and but weakly united to the bone. Through the whole 
extent of the diseased periosteum, the bone was rough from irregular 
absorption of its surface.* 

III. — A man, aged thirty-eight, was admitted into St. Bartholomew's 
Hospital, under the care of Mr. Lawrence, on account of disease in his 
leg, which had commenced several years previously, immediately after 
receiving a severe blow on the shin. Abscesses and ulcerations of the 
soft parts ensued, with many exfoliations of small pieces of bone, at 
different periods, through the next two years. The sore then healed, 
and the parts remained apparently sound through the following seven- 
teen years, when he received another blow on the shin in the situation 
of the old disease. A portion of the integument in consequence mor- 
tified, and its separation was followed by the growth of a soft, very vas 
cular fungus, from the subjacent parts, extending over the lower third 

* Museum of St. Bartholomew's Hospital, First series, Nos. 126, 127. Plate 15 
fig. 2. 

* Museum of St. Bartholomew's Hospital, First series, Nos. 42—42 a. 



284 DISEASES OF PERIOSTEUM. 

of the front of the leg. The surface of the fungus was of a dark red 
colour, minutely tabulated, and discharged a thin sanguineous and foetid 
fluid : it was very soft, bled freely when touched, but was not very 
sensitive. Various remedies were ineffectually applied to the fungus ; 
its base gradually extended over more than half the circumference of 
the limb. Amputation was proposed, but the patient would not assent 
to it, assenting however to any operation not involving the loss of his 
limb. Under these circumstances, Mr. Lawrence removed the fungus. 
The separation of it from the tibialis anticus and extensor digitorum 
muscles was readily effected, and the exposed surfaces of these muscles, 
with their tendons, appeared perfectly sound. But on detaching the 
fungus from the tibia, it was found to have penetrated the wall of the 
bone to its cancellous and medullary texture. The fungus was then 
carefully scooped out of the bone, leaving a large vacancy in it, extend- 
ing to its posterior wall, and to the cancellous texture of its articular 
end. 

Very little constitutional disturbance followed the operation ; the 
whole surface of the wound suppurated freely, and granulations, appar- 
ently sound, arose from the inside of the bone, but in a short time, 
these granulations assumed the appearance of the fungus which had 
been removed, showing that a reproduction of the original disease had 
taken place. The patient now consented to the removal of the limb, 
and on examining it, the fungus was found to have arisen from the 
whole surface of the bone exposed in the first operation.* Twenty 
years after the removal of the leg, this man presented himself at the 
hospital in perfect health. 

IV. — A man, aged fifty, was admitted into St. Bartholomew's Hos- 
pital, with a fungus arising from the lower and front part of the leg, 
of the same character as that described in the preceding histories ; it 
was very painful, and bled freely when touched. At the age of four 
years, he suffered a compound fracture of this leg, the reparation of 
which was complete. About five years before his admission, he struck 
his leg in the seat of the former injury ; a sore in consequence formed, 
which remained open about four years, when the fungus began to 
arise from it, and gradually increased till it measured four inches 
across its base. I amputated the limb, and on examining it, found a 
greyish firm gelatinous substance, extending from the fungus to 

* Museum of St. Bartholomew's Hospital, First series, Nos. 124, 125, Plate 15, fig. 1- 



DISEASES OE PERIOSTEUM. 285 

the subjacent periosteum, which was diseased in the manner already 
described. 

Y. — In the next case, the growth of a fungus from the front of the 
leg was the consequence of diseased actions in the periosteum and 
bone, which had been twenty-five years in progress. The disease com- 
menced shortly after a laceration of the soft parts, with separation of 
the periosteum from the front of the tibia, for which the patient was 
under the care of Mr. Cruikshank. Through the long period of twen- 
ty five years, the leg had not been for a single month wholly free from 
pain. Small abscesses had repeatedly formed over the tibia, accompa- 
nied by numerous exfoliations from it. At length a fungus arose from 
the diseased parts ; it was firm, not lobulated, presenting therefore less 
of the cauliflower-like appearance than in the preceding cases. I remov- 
ed the limb, in accordance with the result of a consultation upon the case 
by Mr. Cline and Mr. Abernethy ; and on examining it, I found the 
fungus extending to the periosteum, which, over the whole tibia, was 
soft and flocculent, and very readily separable from the bone. The 
tibia was enlarged by the increased thickness of its walls*. 

VI.— In the case next related, the disease in the leg was consequent 
on a gun-shot wound, received at the siege of Flushing, thirty-three 
years before the amputation of the limb. The man stated that the ball 
penetrated the bone, from which, a few hours afterwards, it was ex- 
tracted. Abscess and extensive exfoliation of the tibia ensued ; and 
through the long period which had elapsed since the receipt of the in- 
jury, the leg had scarcely ever been perfectly free from pain. A 
broad and very soft fungus arose from the front of the tibia, and dur- 
ing the few months immediately preceding the removal of the limb, 
the man observed the bone to yield at the diseased part. On examin- 
ing the limb, I found that the morbid growth had completely penetrat- 
ed the shaft of the tibia, through about two inches of its length ; and 
it was in this case, that Mr. Paget discovered in the morbid growth, 
the existence of scales like epithelial scales, similar to those which are 
found in carcinoma of the skin, consisting in degeneration of its 
tissue. 

In the foregoing case, the man had long suffered from chronic bron- 
chitis, which, after the amputation of the limb was aggravated, and 
upon this, an attack of pneumonia supervened, from which he sank. 
On examining the body, no morbid deposit was discovered in any of the 

* Museum of St, Bartholomew's Hospital, First series, Nos. 75, 76. 



286 DISEASES OF PERIOSTEUM. 

internal organs ; thus affording confirmation of the view which has 
been taken of this disease, that although malignant in its intractable 
nature, and in its tendency to spread into the deep structures of the 
limb, it is not likely to be followed by the development of similar dis- 
ease elsewhere. 

There can be, I apprehend, no difficulty in distinguishing the disease 
represented by the foregoing cases, from the old incurable ulcer upon 
the front of the tibia, the surface of which is formed by a layer of 
smooth and firm granulations, and the bone beneath which, is enlarged 
and indurated with, in many instances, a circumscribed deposit of os- 
seous matter beneath the ulcer, and exactly of its figure and size. 
Consequent on the old ulcer of the leg, there is no destruction of the 
subjacent parts. But in the disease which has been here described, 
there is destruction of the tissues of the limb, including the bone, with 
a fungous growth from the diseased parts. Directly these characters 
are distinctly manifested, there can be no doubt of the propriety of re- 
moving the limb. 



THE END. 



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